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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP y < d 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE UNIT IVTION 4.,...:.;•�;;P Telephone:(209) 468-3454 Fax:(209)468-3433 Web:www.sitlov.orglehd /Foa 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)476-771 C-57 Contractor Gregg pII ilFng Address 950 Howe Rd City Martinez Lie 485155 Phone (925)313-5800 Consultant/Sub Cntr Clensvnte.c Address 1111 Broadway City Oakland Lie Phone (514)836-3034 Billable Party Cascade, Inc. Address 471 Marie-Victorin Clty Kinesey Falls Zip JOA 1B0 Phone (8 19)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada CONSTRUCTION WORK TO BE PERFORMED: Nr—NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELLIDs DMW-1 throu h DMW-4 ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING ®HOLLOW STEM DIA,OF BOREHOLE 8 In ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 35 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE U4 PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:l4 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION ll.e AIrSoarae.Ozonal®HAND AUGER toip 5 ft GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ft ®BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dla: Casing Depth: Boring DIa: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF_ INCHES TO DEPTH OF FT WELL IDs: [:1 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:0 AUGERS 0 HOSE C PIPE [3 MUSHROOM CAP AT L3 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 Ca ifornia Laws. Signed �+ Title/Company Print Name Ton Smith Date Al DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS t!)Nu2C 5'7iR�ET WORK PLAN DATED APPLICATION ACCEPTED BY Yl�, 4.-cci✓(_ DATE I GROUT INSPECTION BY FINAL INSPECTION BY - 'DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST I PR# 7`9 $125 x l U 2S �`�K' 1 (�`I !L SR# (vim RO# ayo� 7�j (3500) PR# (2900 ENCROACHMENT DOC C-57 WC ✓ WAIVER_ Al a C57 LETTER OF AUTHORIZATION TO SIGN PERMIT �/