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( 2/ "c"•-- ..% a• .., *-4' <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com -0'06 ..... <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. Fremont St (Formerly 424 Van Buren St) City/State/Zip Stockton, CA 95203 <br />Phone <br />Cross Street N. Van Buren Street ApN 137-410-02 <br />Property Owner* The City of Stockton - Economic Development Department <br />Phone <br />Address 400 E. Main Street, 4th Floor City/State/Zip Stockton, CA 95202 <br /> <br />C-57 Contractor Cascade Drilling <br />3000 Duluth Street West Sacramento, CA 95691 Address City/State/Zip <br />Stantec Consulting Services, Inc. Consultant/Sub-Contractor License# <br />Address 3675 Atherton Road City/State/Zip Rocklin, CA 95765 <br />License# <br /> 938110 Phone 530 59 / -26E1- <br />Phone iP 41-2--78e) <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE <br />MONITORING 0 HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />la SOIL VAPOR PROBE —S-0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Spaniel, Ozone) El HAND AUGER <br />13 OTHER 0 OTHER: <br />WELL/SOIL BORING IDs SV-1 , SV-2, SV-3 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 6 feet <br />DIA. OF BOREHOLE 4 or 6 inches <br />CASING THICKNESS 0.25-inch tubing <br />CONDUCTOR CASING El Yes KI No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 8 No <br />GROUT SPECIFICATIONS <br />in BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC El OTHER Tygon or Nylaflow, or equivalent <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS CI HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />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 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 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 />0 C-57 0 C-57 Authorization for Other to Sign Permit El 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 />END 29-01 10-26-2015 <br /> <br />Site Mitigation Well Permit Application <br />Signed <br />Print Name uonnne AcKerman