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ORIGINAL SAN JOAQUIN COUNTY NOW e ENVIRONMENTAL HEALTH DEPARTMENT LOP a Z�l 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • •. �;:? Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sugov.org/eh UNIT IV q�iFpR 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 242 North Sutter Street Cross Street Calitomia Street City/State Stockton.CA Zip 95202 APN 13925005 Property Owner Sutter Office Center Address 2001 Union Street,Suite 300 City/State sar,1rancis ,CA Zip 94123 Phone 415447-6838 C-57 Contractor Cascade Drilling LLC Address 3000 Duluth Street City/State West Sac,CA LIC 938110 Phone 916-638-1169 Consultant/Sub Cntr ARCADIS U.S,Inc Address 101 Creekside Ridge Court,Suite 200 City/State Roseville,CA Lic Phone 916-78"320 Billable Party ARCADIS U.S,Inc Address As above City/State Zip Phone GIS Coordinates X Y CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT.GEOPROBE,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❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Cl STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Q.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING ElNo C3Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY 6 #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF B INCHES TO DEPTH OF 40 FT WELL IDS: MW-1,MW-11),MW-2,MW-3,MW4,MW-5 ❑PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neaice—tv❑EXPLOSIVES FROM See B-tPlan TO Arraa,ea FT BELOW SURFACE TREMIE TYPE TO BE USED:Lj AUGERS HOSE El PIPBE OW SURF C E [L ®MUS ROOM CAP AT(>3 FT Fr. COMMENTS See blast plan for individual well exolosives intervals MW 1 T U b �C 1 Cf'(� ��i�L �1�/ t / r �l r-� =U �D�� • 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 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,alicLall applicWUA,--,,-, alifornia laws. Signed Title/Company Project Scientist/ARCADIS U.S.,Inc. Print Name A&L Munn Date September 18,2014 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS Z Z N �u7 Tek J� T / s I GL'K 16 JV WORK PLAN DATED APPLICATION ACCEPTED BY C DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE ? ? �° REQUEST PR# !� $ 130x (Q 0 ( ?j0()s-�7 1 q. SR# SD3 60-70 La- RO# (3500) OUDUS PR# 2900 C-57 f)( WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT X ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP