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oAa�t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ..Au < LOP 1868 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION Telephone: 209 468-3454 Fax: 209 468-3433 Web:WWW.slilaov.orla/ehd UNIT IV 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 Property Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton Zip 95207 Phone (209)476-7710 C-57 Contractor PeneCore Drilling Address 1238 Alice Street.Ste A City Woodland Lic 906899 Phone_(530)661-3600 Consultant(Sub Cntr Gensyntec Address 1111 Broadway City Oakland Zip 04607 Phone (510)836-3034 Billable Party Cascades.Inc. Address 471 Marie-Victorin City Kinesev Falls Zip JOA IBO Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) M SOIL BORING IDsRS S th,giioh RH-19 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2.25-inch❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: NA _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER NA _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 40 ft _TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 15 M SOIL BORING I@ PUSH POINT(GPI CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ti.e_Air Some.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casino Dia: Casing Depth: Boring Dia: COMMENTS: Hand auger to 5 it,continuous coring to-40 ft temp well groundwater sample at 40 ft NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY1 #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATI DNS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS 0 HOSE El PIPE ❑MUSHROOM CAP AT p3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I 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 CallforrAa Laws. Signed rig I S Title/Company Seninr Staff Fngineer,Gen yl3tcr.Consultants Print Name Tony Sr lith Date 13 Februaiy 2D13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS Uc tgLyGLW_E(Sri `jT � WORK PLAN DATED J AIV Lk AKv) 2 2 ZO 1`3 APPLICATION ACCEPTED BY qy Kuw( DATE ISSUED 2"�" /-5 AREA 10? GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE c' (,.� REQUEST PR# O J $125 x I F 11 s16 Cv Lwr* �"(�-13 SR# Lr 6(O RO# 3500 PR# 2900 C-57 WCy WAIVER-_ _12X57 LETTER OF AUTHORIZATION TO SIGN PERMIT 4VENCROACHMENT DOC