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ORIGINAL <br /> SAN JOAQUIN COUNTY �. <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> `•=• — 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sj9ov.org/eh UNIT IV <br /> \IK'p-'RNA <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 /> 13925005 <br /> 95202 <br /> Site Location 242 North Sutter Street Cross Street California Street City/State Stockton,CA Zip APN <br /> Property <br /> Owner Sutter Office Center Address 2001 Union Street,Suite 300 City/State San Franc,c.CA Zip 94123 Phone 415-447-6838 <br /> C-57 Contractor Cascade Drilling LLC Address 3000 Duluth Street City/State well Sac,CA Lic 9110 Phone 916-638-1169 <br /> Consultant/Sub Cntr ARCADIS U.S.,Inc. Address 101 Creekside Ridge Court,Suite 200 City/State Roseville,CA Lic Phone 916-766-0320 <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDS <br /> ❑ OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e,Air Sparge.ozones❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING❑No ElYes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD-(CHECK ALL THAT APPLY) <br /> z #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF t9 INCHES TO DEPTH OF 80 FT <br /> WELL IDs: M 6 M 6D ❑ PRESSURE GROUT TO DEPTH OF <br /> GROUT SPECIFICATIONS Neatcement FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:El AUGERS LJ HOSE PIP ED EXPLOSIVES FROM s-w-,P,_ To Aaacnad FT BELOW SURFACE <br /> COMMENTS jj���, f MU$ORQOM CAP AT(>3 FT) FT BELOW SURFAC€ <br /> - bla t Calan for individual well explosives intervals, 4V- <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,an Fap licabCalifornia laws. <br /> Signed Title/Company Project Scientist/ARCADIS U.S.,Inc. <br /> Print Name JulielliIjI.n, <br /> Date September 18,2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z-LI 7- Li-TT1 f ST-Cc V,t0 VV <br /> WORK PLAN DATED /' 'y <br /> APPLICATION ACCEPTED DATE ISSUED CiZZJ/ <br /> AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> REQUEST PR# INVOICE <br /> 5 0 - $ 130 x 2— I JUC"tis as SR# <br /> v RO# <br /> - --- (3500)OJih? <br /> PR# <br /> 2900 <br /> C-57 >< WC ,< WAIVER <br /> EHD 29-01 7/24/14 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br />