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`+.w� `r✓ P Y Ot'4�tN� ,..•_ ,,�t•.•o SAN JOAQUIN COUNTY --_ ENVIRONMENTAL HEALTH DEPARTMENT LOP y SITE MITIGATION ' `':• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV ... R... ...N;P Telephone(209) 468-3454 Fax:(209) 468-3433 Web:www.siUov.orCl/ehd r ll Ow WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 0* t NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fV 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,an the Stand rds of the San Joaquin County Environmental Health Department. Site Location 800 West Church St. Cross Stree t 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 Gregg Drilling&Testing Address 950 Howe Road City Martinez Lie 485165 Phone (925)313-5800 Consultant/Sub Cntr. Geosyntec Cons. Address 475 14th Street City Oakland Lie Phone (510)285-2700 Billable Party Geosyntec Cons. Address 475 14th Street City Oakland zip 94612 Phone (510)285-2700 GIS Coordinates:It x-121.302736 f xt 37.943958 CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT(tEOPROB HYDROPUNCH,HAND-AUGER,OTHER) _ ❑SOIL BORING IDS ❑WELL IDs 11 0-1-HER IDs 0 TYPE&#OF WELL/80RiNU INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (SG-2 through SG-6) ^, —U PAONITURING U HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: �J _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER �©SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE M PIPE' —[7 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.AirSoarne.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH - BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING EI No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: -- NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DEStRUICTION METHOD: CHECK ALL THAT APPLY 5 #OF WELL(S)TO BE DESTROYED M OVER-BORE DIAMETER OF INCHES TO DEPTH OF_jj) FT WELL IDs: S6-2 through SG-6 ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Bentonite ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS All locations to be backfilled with bentonite one day after installation. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that 1 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 r,:r%c 4—=x. k�4 -.- __Title/Company Engineer,Geosyntec Consultants Print Name � ,, Jackie Lanzori' Date 26 January 2011 1 DEPARTMENT USE ONL e 27 50 SITE MAP IN UNIT IV FILE-SITE ADDRESS_ $DO C�.��,� '„� 57KA, WORK PLAN DATED APPLICATION ACCEPTED BY DA W . AREA�� GROUT INSPECTION BY FINAL INSPECT] N 7B DATE1•' I� DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE S REQUEST OPR# ZtoZ $122X �. $16 Z.•3• SR# bt 8q l 2903 lowed -%ftE UJa..Seo bz zs o OSI(0(0 - EHD 29-01 07/28/10 C WAIVER C-57 LETTER OF AUTHORIZATION T SIGN IT ' f ROACHMENWE O PERM APP E '�� W;��5