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,oPa V I ty. so SAN JOAQUIN COUNTYF ILE G""0111Y <br /> a ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> y { 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> N Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <br /> FOR <br /> WELL & BORING PERMIT APPLICATION <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 W.Church Street Cross Street Stockton Street City Stockton Zip 95203 APN 145-230-04 <br /> Property <br /> Owner Newark Group Address 20 Jackson Drive Cit Cranford <br /> City Zip 07016 Phone <br /> C-57 Contractor Address City Lic Phone <br /> Consultant/Sub Cntr WEST,Inc. Address 711 Grand Ave.,Suite 220 City San Rafael Lic CE 44031 Phone 415/460-6770 <br /> Billable Party WEST,Inc. Address 711 Grand Ave.,Suite 220 City San Rafael Zip 94901 Phone 415/460-6770 <br /> GIS Coordinates:X. 3 5 <br /> —Y a/.16-3 <br /> . 11 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPROBE,HYDRO UNCH,HAND-AUGER,OTHER) <br /> ElSOIL BORING IDs / <br /> ❑WELL IDs <br /> ®OTHER IDs—SS-1;SS-2;and SS-3 <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> --0EXTRACTION:Vapor/Water ®HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> --!-[M 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.e.Air Sparge.Ozone l AND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ®OTHER: see below APPROX.BORING DEPTH 5-feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> • <br /> COMMENTS: Soil vapor probe rods CONDUCTOR CASING❑No[IYes:Casing Dia: Casing Depth: Boring Dia: <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_Borings were backfilled with bentonite and hydrated <br /> 5 WORKING DAYS NOTICE REQUIRED AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify-1b have prepay this ation and t t the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,anrLall a le liforni s. <br /> Signed f Title/Company President/WEST,Inc. <br /> Print Name P ter Krasnoff Date November 9,2010 <br /> EPARTMENT US ONLY Zl- 56 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED ATO 2K �- <br /> APPLICATION ACCEPTED BY <br /> AREA <br /> GROUT INSPECTION BY FINAL INSPECTION DATE ll 17-/V <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# <br /> q REQUEST PR# INVOICE <br /> Z`� � $122x KL 1221C2 = Z tti I/ /j/D SR# <br /> Q ,� _ 6 <br /> 2— RO# <br /> 3500 <br /> 76 z 00 -5/ ro l y <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN P �I� ENT DOC <br /> EHD 29-01-07/28/1 o <br /> WELL PERMIT APP <br />