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r �oPa..!K. SAN .JOAQUIN COUNTY 2' ? ENVIRONMENTAL HEALTH DEPARTMENT LOP cr ' SITE MITIGATION a: < 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/ehd PAYMENT WELL & BORING PERMIT APPLICATION RECEIVED FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 3 Z011 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOVl► �,Q�.Q�J NTY Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in colpf6(Hdow Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. HEALTH DEPARTMENT 833 East 8th Street S. Sacramento Street Cit Stockton Zip 95206 APN 177-02-23 Site Location_ _ Cross Street y Property Union Pacific Railroad Address 9451 Atkinson Street City Roseville Zip 95747 Phone Own916-789-5184 Owner _ Own C-57Contractor Penecore Address 1238 Alice St.Suite A City Woodland Lic_906899_Phone 530-661-3600 _ Consultant/Sub Cntr_ARCADIS-US _ Address 1410 Rocky Ridge Dr. City Roseville Lic Phone 916-786-0320 Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO QF PERFORMED: NEW WELL/BORING(CPT(GEOPROBE YnRr1Pl INr.H HANn-AI Ir;FR nTHFR) SOIL BORING IDs C-1a to C-6a GP-58,C-8a,C-15a to C-18a,__D-20a D-26a to D 30a D-32a,B-4a/b/c D-23a to D-25a,D-31a/b/ _ WELL IDs c GPP=5a GP-7a.GP-16a and D-11a.32 Borings total ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE -Lin _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER III------III❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: CI AUGERS C3 HOSE C3 PIPE 90 SOIL BORING �X PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION r e Air Soaroe Ozone/❑HAND AUGER _ GROUT SPECIFICATIONS ❑OTHER: ❑OTHER:_ APPROX.BORING DEPTH—10 Feet C]BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION METHOD'(CHECK ALL THAT APPLY) DESTRUCTION WORK TO BE PERFORMED: ❑ #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 ❑HOSE (-) PIPE C1 MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I h ve repared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulatio s,and all ap li able California Laws. Signed � Title/Company P�sjP S i��f S 11490 4 DT$ Print Name Scott- �K-✓ ^�1 Date-1�-2-If _ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FIL SITE ADDRESS — WORK PLAN DATED IVI t I I I DATE ISSUED APPLICATION ACCEPTED BY / I �� « y / AREA 9" FINAL INSPECTION BY DATE GROUT INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTSICONDITION§: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE gj!EE INFO AMT REMITTED CHECK# R/ECV'D BY DATE / REQUEST PR# 125x I [ 2, ��-46-s1 14- ( ( 1 SR#00�3aZRO#3'7� 3500 ENCROACHMENT DOC C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT