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oort - <br /> VIM SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION <br /> .. ;4 Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.slaov.ora/ehd UNIT IV <br /> /FQaia <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 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 Lldlling Address 950 Bowe Rd City Martinez Lie 485165 Phone (92-9113-5800 <br /> ConsultantlSub Cntr rPncymtrc. Address 1111 Broadwav City Oakland Lic Phone (510)836-3034 <br /> Billable Party Cascades Inc. Address 471 Marie-Victorin City Kinsey Falls Zip JOA 1110 Phone (819)363-5702 <br /> GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT.GEOPROSE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> M WELL IDs DMW-1 through DMW-4 <br /> D OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,_.-®MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 8 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL 29 PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 35 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE R PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:l4 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —[]INJECTION(I.e AlrSoaMe Oronal®HAND AUGER top 5 ft GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ft ®BOLTED TRAFFIC BOX OR ®STOVEPIPE <br /> j CONDUCTOR CASING KI No❑Yes:Casing Dia: Casing Depth: Boring Die: <br /> COMMENTS: <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 L?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 6 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> 1 hereby certify that 1 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 CalIfornla Laws. �� �+ <br /> Signed •SA•rvtTitle/Company geninr Staff Fngince,,r�rienS;hyy�_nnmiltanlc <br /> I Print Name Ton Slnilh Date­91 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS � � (t), d Nu2e-f f STT6Z�ET <br /> WORK PLAN DATED Sc l 2v f Z <br /> APPLICATION ACCEPTED BY DATE ISSUED 11-7—r2— AREA / -q2 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSMONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RD# INVOICE <br /> REQUEST PR# <br /> d I $125. �� (�2� L�4EC% ��`/'f G_ SR# fc/J <br /> O� 75 300 <br /> PRO <br /> (2900 <br /> C-57 WC ✓ WAIVER�Al[a C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />