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SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT .1111 <br /> OP <br /> • '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> %ROR�•* Telephone: (209) 468-3454 Fax:(209)468-3433 Web:www.sicl&o N&IENTAL WLTTI11f <br /> WELL & BORING PERMIT APPLICATION—I /SERVICES <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 800 West Church St Cross Street Stockton St City Stockton Zip 95203 APN 14523004 <br /> Property <br /> Owner The Newark Group Address 2575 Grand Canal Blvd City Stockton zip 95207 Phone (209)476-7710 <br /> C-57 Contractor Gregg Drilling_ Address 950 Howe Rd City Martinez Lic 485165 Phone (925)313-5800 <br /> Consultant/Sub Cntr C;eosyntec Address 1111 Broadway City Oakland Lic Phone (510)836-3034 <br /> Billable Party Cascades,Inc. Address 471 Marie-Victorin City Kingsev Falls Zip JOA 1BO Phone (819)363-5702 <br /> GIS Coordinates:X -121.302736 Y37.943958 (Quebec),Canada <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> [$I NEW WELL/BORIN CPTEOPROB YDROPUNC AND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> El OTHER IDs CPT-2012-01 through CPT-2012-18 with possibility of 2-3 additionaUprovisional locations <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE NA CONSTRUCTION SPECIFICATIONS NA <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i a.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> 21 RI OTHER: CPT/14P ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: 1 CPT and 1-2 hydropunch borings per location Neat cement grout backfill upon removal <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California Laws. <br /> T Title/Company Ceninr Staff FnginPP,r,sieptyntPr Conenitants <br /> Signed / � , S <br /> Print Name Tony Smith _ Date 17 July 2012 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125 x SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />