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t r Q�rN t zR ' NA L SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP E a y. < SITE MITIGATION ,�";'• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV rFOfR�'`P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siclov.ora/ehd 010WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION )�O?kb 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 Gregg Drilling&Testing Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800 Consultant/Sub Cntr Geosyntec Cons, Address 475 14th Street City Oakland Lic Phone (510)285-2700 Billable Party Geosyntec Cons. Address 475 14th Street City Oakland Zip 94612 Phone (510)285-2700 GIS Coordinates:X_ 3-4.1 q 5 p-7 IZi.9 0 3, CONSTRUCTION WORK TO BE PERF ®NEW WELL/BORING(CPT EOPROB YDROPUNCH HAND-AUGER,OTHER) ✓C�-/�� 6 ❑x SOIL BORING IDs SBA through SB-6 ❑WELL IDs 02t OTHER IDs C TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 1Z ❑EXTRACTION:Vapor/1W IatteerD ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC [I OTHER /=®SOIL VAPOR43RME W ❑MUD ROTARY DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _L29 SOIL BORING/Hydropunch ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fr) _❑INJECTION Q.9.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Bentonite _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 10-20 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: All locations to be backfilled with bentonite NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHATAPPLY) #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:ElAUGERS ❑HOSE C]PIPE C1MUSHROOM CAP AT(>3 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 California laws. Signed Title/Company Engineer,Geosyntec Consultants Print Name 0 Jackie L zon Date 18 January 2011 DEPARTMEN USE ONLY ('��.e., Z$.50 SITE MAP IN UNIT IV FILE-SITE ADDRESS �S'D WORK PLAN DATED ZO I I APPLICATION ACCEPTED BY DS3NJ '-3 .;<<+� -- AREA GROUT INSPECTION BY Z Z FINAL INSPECTION B �� 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 REQUEST PR# �Ro $122. 122. o �� SR# ?4 2, 2801 5-� 12,2-1 to l O ogy6ye J D(Q f_BgZ C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN ERM/ ENT C O EHO 29-01 07/28/10 ; r WELL PERMIT APP ;. ��l t