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COPY t _ SAN JOAQUIN COUNTY y ENVIRONMENTAL HEALTH DEPARTMENT Lop �. g 1868 East Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION ' UNIT IV � •. . Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.slaov.org/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. } Site Location 800 West Church St Cross Street Stockton St City Stockton zip 95203 APN 14523004 J Property Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton Zip 95207 Phone(209)476-7710 C-57 Contractor Gregg Drilling Address 950 Howe Rd City Martinez Lie 485165 Phone(925)313-5800 Consultant/Sub Cntraen.;ntec Address 1111 Broadway City Oakland Lie NA Phone (5 101836-3034 Billable Party Cacradrg.Tnc. Address 471 Marie-Victorin City Kingsey Falls zip JOA 1BO Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada t CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELLIBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs BH-15 to BH-16 ❑WELL IDs - EI OTHER IDs " :soil gas probes SG-7 to SG-8 'E TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (SG-7 to SG-8) _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 21n. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DtA:Nylarlow _❑EXTRACTION:Vaporl Water [3HAMMERIDRIVEN CASING THICKNESS 1/4 in. TYPE OF CASING: ❑STEEL ❑PVC ® OTHER 2 KI SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [$I PIPE ! 2 KI SOIL BORING 50 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I.e.Airsparge.Ozonel❑HAND AUGER GROUT SPECIFICATIONS bentonite j I W OTHER:,C.PT/r3P ____ ❑OTHER: APPROX.BORING DEPTH 5 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING 10 No❑Yes:Casing Dia: Casing Depth: Baring Dia: COMMENTS: I CPT and 1-2 hydiopunch borings per CPT location Neat cement grout backfill Upon removal in CPT and BR borings. ' NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) I --2—#OF WELLS)TO BE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: S.G-7 anr♦Rr .a ElPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONSt E]EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:[IAUGERS HOSE 10 PIPE ❑MUSHROOM CAP AT(>3 Ff) Fr BELOW SURFACE COMMENTS all Iorationa to he hnrkfillPd with neat rempnt the garne day ac Installation 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS jI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable California Laws. Signed Title/Company CPninr Ctaff1Rngine -Gensynter ransnitanta Print Name T n Smllh Date_ 99 July 2013 DEPARTMENT USE ONLY / SITE MAP IN UNIT IV FILE SITE ADDRESS v 00 12t4h( S T2C-FT M1 7-0't)Q l(2 WORK PLAN DATED_ f3 C(dwA-,T APPLICATION ACCEPTED BY -1•�G>tKu►'h DATE ISSUED -AREA GROUT INSPECTION BY FINAL INSPECTION BY J �0*Kuu. DAT Z'/3 DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# � 21v6 agQ JU1- B6So5 $125x y I / o5 i R# 62� 1716- 10W3 # OUD C-57_� WC I/ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V_ENCROACHMENT DOC