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tiL� LY L�JvL; pop . 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.sisaov.ora/ehd UNIT IV 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 Greer Drillina Address 950 Howe Rd City Martinez Lic 485165 Phone(925)313-5800 Consultant/Sub Cntr Geosyntec Address 11 I I Broadway,6th Floor City Oakland Lic Phone (510) 836-3034 Billable Party Cascades.Tnc. Address 471 Marie-Victorin City Kinpsey Falls zip JOA 1130 Phone (819)363-5702 GIS Coordinates:X -121.302736 Y 37.943958 (Quebec),Canada 37,'W5 -IF-/. .->56 CONSTRUCTION WORK TO BE PERFORMED: ®NE EL ORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs El WELL IDs DNfW-5A ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 ©MONITORING , 91 HOLLOW STEM DIP..OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: __❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS Sch 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL "30 ft b9S TREMIE TYPE TO BE USED: M AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ESI No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I e.0.r Some.Ozonel❑HAND AUGER GROUT SPECIFICATIONS Neat cement arout _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 40 ft ❑BOLTED TRAFFIC BOX OR IN STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dia COMMENTS: 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 0 HOSE 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 Calif mia Laws. Signed &-), : Title/Company Fn-ineer osyntec Consults/nts Print Name TonAmith Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 0,L1#UkCfV 7-., 5rzV—<r"J WORK PLAN DATED j'4jw-4R APPLICATION ACCEPTED BY .I 0 DATE I rJ / —nr3FA G GROUT INSPECTION BY FINAL INSPECTION BY 41 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# /`40 $125X ( 2�j9 85.?— 7,—(7-1 RO# (3500) PR# 2900 C 57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT_---k::'-ENCROACHMENT DOC_w r/h