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" c (( SAN JOAQUIN COUNTY �� - • ��+• 1 ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION c P' Telephone: 209 468-3454 Fax: 209 468-3433 Web:www.s' ov.or /eh WELL & BORING PERMIT APPLICATION aFOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATlct#Ay 19 �01 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ane,, Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is�cr�pR0N&X"Lw'A `T Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartmMRMIT/SERVIC"�E.S S Site Location 800 W.Church Street Cross Street Stockton Street City Stockton Zip 95203 APN 145-230-04 Property Owner Newark Group Address 20 Jackson Drive City Cranford Zip 07016 Phone C-57 Contractor EnProb Address P.O.Box 6093 City Oroville Lie 777007 Phone 530/589-2019 Consultant/Sub Cntr WEST,Inc. Address 711 Grand Ave.,Suite 220 City San Rafael Lie CE 44031 Phone 415/460-6770 Billable Party WEST,Inc. Address 711 Grand Ave.,Suite 220 City San Rafael Zip 94901 Phone 415/460-6770x4LR GIS Coordinates:X 6330221.25' Y 2167104.5' CONSTRUCTION WORK TO BE PERFORMED: a ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) IN SOIL BORING IDs W-1 and W-2 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑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 ❑PIPE EI SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20-feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 1 CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Advance borings for collection of soil and groundwater samples 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: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Borings will backfilled with Portland Type II cement grout. 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that-1 have prepared this applic 'on and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and 11 applic le C ornia I - Signed Title/Company President/WEST,Inc. Print Name Peter Krasnoff Date May 12,2011 DEPARTMENT USE ONLY �f SITE MAP IN UNIT IV FILE-SITE ADDRESS Vd WORK PLAN DATED J�7i APPLICATION ACCEPTED BY DATE ISSUED S-2 �l AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COM MENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# ZROI $122. SR#�(oys� del 14� I° X66 z oo) L I C-57WC WAIVER C-57 LETTER OF AUTHORIZATION TOSISIGAI P�RV ENCROACHMENT DOC /U EHD 29-01 07/28/10 V WELL FERMI APP i 1 1�