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RIG ► 'Il A " U1N SAN JOAQUIN COUNTY o�' ` ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION <� 1868 Hazelton Avenue, Stockton, 95205-6232 UNIT IV 4 Telephone: (209) 468-3147 Fax:(209) 468-343333 Web:yvww.siaov.ora/eh WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMff EXPIRES 1 YEAR FROM DATE ISSUED s apitilication is made ------ Application is hereby e ad to Till Jcoaquin County for a hap chapter 9- 15.3,and the Standards of the San Jto construct an(yor oaquin n th-County Environmental HeaCl Department. compliance with San Ju.C/3A j8 T cellaom s ser"t CitylState sm°°" z pgm APN 139-24-009 Site Location 437 East M, r Ave Cross Street Property 6111 aaNer Cairym RQ Room 3652 CitylState sen izts O CA ZP� Phone 925 13a2US Owner chs+m E""�"en'I MarWmnwt Address wast s.n:nw Lic MID Phone 91ea36.1tM Cascade Drilling LLC Address 3000 Duluth Brest CitylState C-57 Contractor Rose %.CA Uc Phone 916-76ea32o ARCADiSU.s.,lnc. Address fol Creekade Wage Crud,Buee 200 City/State ConsultanUSub Cntr es: � �� CitylState Zip Phone Billable Party Address GIS CoordinatX 7.45.720 Y -12/1 28983 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELIJBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTLLEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED-. ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION I.,Ai.Ssame.Orme)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia Casin90aplic_Boring Dia:__ COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLDUT AP-LY) 3 #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF_INCHIESTODEPTHOF Fr WELL IDs: u1+.u,:.uu El PRESSURE GROUT TO DEPTHOF FT BELOW SURFACE GROUT SPECIFICATIONS w+ '+^' EI EXPLOSIVES FROM sn.crd TO T 9,LOW SURFACE TREMIE TYPE TO BE USED: AUGERS HOSE PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS See blast forIndIviduaLweil e.plosives,ioletval. 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 I ,.all/applicable California laws. Alm,/ f- L (.� T9e/Company Project Scientist l ARCAM U.S.Is,G Print Name J D.Musa Date Seoternber5.2e14 DEPARTMENT USE ONLY SITE MAP IN UNIT N FILE-SITE ADDRESS 0114+Lee &AIr -;- rW.</J-dW WORK PLAN DATED 2,01V APPLICATION ACCEPTED BY 6 ►,�•11CGflii7 DATE ISSUED 45 -7c-( AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE CO M ME NTSICONDITIO NS: ACCOUNTING ONLY: AID# FAC# PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST I PR 35 $13OX 3 G o Np> A 2 -IU-/ SR# 7O}5 3,S-o3 3cIO RO# 3500) z PR# 2900 C-57r/4/14 WC WAIVER�iL , C-571 ETTER OF AUTHORIZATION TO SIGN PERMIT EHD 29 OI 7 !� ENCROACHMENT DOC Alit? WELL PERMIT APP