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C?r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP • 1868 East Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION •. Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sipov.orp/ehd UNIT IV ..oa WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 Address 950 Howe Rd City Martinez Lic 485165 Phone(925)313-5800 Consultant/Sub Cntr Gen rvl Mp, Address 1111 Broadwav City Oakland Lic Phone (510)836-3034 Billable Party Cascades,Inc. Address 471 Marie-Victorin City Kingsev Falis Zip J0A 1130 Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada Z7-15 1 2-f. Scr CONSTRUCTION WORK TO BE PERFORMED: [19 NEVJWELLOORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER) ❑SOIL BORING IDs El WELL IDs DM W-58 ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _L[Z]MONITORING 13 HOLLOW STEM DIA.OF BOREHOLE 14" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water ❑HAMMER/DRIVEN CASING THICKNESS Srh 40 TYPE OF CASING: ❑STEEL IN PVC ❑ OTHER _❑SOIL VAPOR PROBE ®MUD ROTARY DEPTH OF GROUT SEAL-70 ft has TREMIE TYPE TO BE USED: Ig AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:IS Yes ❑No(MAXIMUM FREE FALL DEPTIi IS 30 FT) _❑INJECTION(Im Ar$Dome,Ozonel❑HAND AUGER GROUT SPECIFICATIONS NPntrgernentgrout ,❑OTHER: ❑OTHER: APPROX.BORING DEPTH 75 fl bas ❑BOLTED TRAFFIC BOX OR M STOVE PIPE CONDUCTOR CASING❑No®Yes:Casing Dia: 10" Casing Depth5D ft 2QSBodng Dia:14" COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY1 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FTSELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: MG-G-UERSO HOSE EI PIPE ❑MUSHROOM CAP AT L3 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 f i� n!� Title/Company Fng,ineer Giencvntec Coll""ll its Print Name Tony SI»ith Date_�� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS Ob J,) JHit Pri1 T rQEcf7' <FUe< WORK PLAN DATED . �+,+42�1 `gOl 2vI N APPLICATION ACCEPTED BY �J• ►tire _ DATE ISSUED 2- -r`I' AREA 16 G GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIO NS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE G G REQUEST PRO [v S 125x t u5 e -601 T- r 2-lT-rSl SR# lC) _ 1 - RO O 2�tv� 3 7S 3500 PRO 2900 WC 1, _WAIVER C57 LETTER OF AUTHORIZATION 70 SIGN PERMIT ENCROACHMENT DOC__ 19