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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> c I 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone:(209) 468-3454 Fax:(209) 468.3433 Web:www.sinov.oro/ehd UNIT IV <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 3015 Navy Drive Cross Street West Washington Street city Stockton Zip 95206 APN 14503010 <br /> Property <br /> owner Port of Stockton(Rita Koehnen)Address 2201 West Washington Street City Stockton Zip 95206 Phone 209-946-0246 <br /> C-57 Contractor Cascade Drilling, L.P. Address 3632 Omec Circle City Rancho Cordova Lic 938110 Phone(916)638-1169 <br /> Consultant/Sub Cntr ETG Address 1176 West 7th Avenue city Eugene Uc Phone 541-743-2600 <br /> Billable Party TOC Holdings Co. Address 2737 W.Commodore Way City Seattle Zip 98199-1233Phone 206-332-1453 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs GP-1 through GP-45 <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE 8#OFJONWORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3 in. ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> _0 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF eCASING: ❑STEEL 0 PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE [3 �MUD ROTARY DEPTH OF GROUT SEAL 3 MASN( 15109&ED: 0 AUGERS 0 HOSE ❑PIPE <br /> 45 MOIL BORING 13 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(NAAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(I.e Ar Soene.Ozone)IN HAND AUGER GROUT SPECIFICATIONS_ <br /> _O OTHER: 0 OTHER: APPROX.BORING DEPTH 10 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING NNo 0 Yes:Casing Dia: Casing Dep;: Boring Dia:_ <br /> COMMENTS:All borings will be decommissioned using bentonite chips hydrated with potable water.p/ 30 0 �Dk 5 <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 D HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California Laws. <br /> Signed 1::;1kTitle/Company Sr. Operations Manager/Cascade Drilling, L.P. <br /> Print Name Paul Snelgrove Dale6/15/2012 MANIA�PIINI'IYfLNT <br /> DEPARTMENT USE ONLY RECEIVED <br /> SITE MAP IN UNIT IV FILE SITE 3A�il✓�. <br /> 615" <br /> 'A 'v <br /> WORK PLAN DATED J 0/Z JUN ` o ZUIZ <br /> APPLICATION ACCEPTED BY / DATE ISSUED � nnlw�(�.ftINTY <br /> GROUT INSPECTION BY FINAL INSPECTION BY ENVIROM6A>iTLAL <br /> DESTRUCTION INSPECTION BY, DATE HEALTH DE ARTIVIENT— <br /> COMMENTS/CONDITIONS: Gy/lCtVGfLR Z/ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE O# INVOICE <br /> na ` 1 REQUEST PRR# <br /> !/! DJ $125 X J�Z 3D3 SR# OP ZQ <br /> ?/JD3 X375 375 �3bZ Ro# <br /> PR# <br /> 2900 <br /> C-57 WC V WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />