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C-57 Contractor Cascade Drilling <br />Consultant/Sub-Contractor Stantec Consulting Services, Inc. <br />License# <br />City/State/Zip <br />License# <br />938110 <br />West Sacramento, CA 95691 <br />6-50 <br />'flip 472- Scien <br />Phone <br />Phone <br />Address <br /> 3000 Duluth Street <br />RECEIVED <br />AL 1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />ENVIRONMENT <br />PERMIT/sERImHEALTHEs Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />SITE MITIGATION 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. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 310W. City/State/Zip Fremont St (Formerly 424 Van Buren St) Stockton, CA 95203 Phone <br />Cross Street N. Van Buren Street APN City of Stockton ROW <br />Property Owner* The City of Stockton <br />Phone <br />Address 425 N. El Dorado Street City/State/Zip Stockton, CA 95202 <br />SAN JOAQUIN COUNTY FEB 27 2018 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Address 3875 Atherton Road <br />CONSTRUCTION WORK TO BE PERFORMED: *Note <br />City/State/Zip Rocklin, CA 95765 <br />Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER <br />MONITORING 0 <br />EXTRACTION (Vapor/Water) 0 <br />SOIL VAPOR PROBE <br />in SOIL BORING 1 ID <br />El INJECTION (Air Sbarcie. Ozone) <br />13 OTHER 0 <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS at least 5 past water BORING DEPTH est to be —15-20' <br />DIA. OF BOREHOLE -4 inches <br />CASING THICKNESS <br />CONDUCTOR CASING CI Yes V1 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes rA No <br />GROUT SPECIFICATIONS <br />BOLTED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING CIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER None-soil boring <br /> <br />Boring Dia: Casing Dial Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />WELL/SOIL BORING IDs SB-2 <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE El PIPE <br />0 OVER-BORE <br />El PRESSURE GROUT <br />0 EXPLOSIVES <br />0 MUSHROOM CAP <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />- :ounty Ordinance Codes and Standards, and all other applicable California laws. <br /> Title/Company Stantec Consulting Services, Inc <br />Date 02/22/2018 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />i <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit $139x <br />EHD 29-01 10-26-2015 <br />Site Mitigation Well Permit Application <br />Signed <br />Print Name uorinne Amerman