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SAN JOAQUIN Environmental Health Department —COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS 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 San Joaquin County Well Standards. Job Address 267oo Smdheenta Rd. C/Y�+(JV• CilylStatelZip T-wwKAAnM53044y1 or•„nd.�.w. Cross Street W.Linne Rd. APN 25�� W � ,TiAf Property Owner* olin Corporation Cv >911Z K O F ,.,.�(40e)5geao30 Address 3855NoM0coee St.Suite1100 City/State/Zip ClevelanMW37312 C-67 Contractor Cascade License# 1058336 Phone (510)478-0858 Address 120 S.23rd SL City/State/Zip Richn'00NCA194804 Consultant/Sub-Contractor Wood. License# PG 10032 Phone (510)637-8057 Address 55512th Street,Suite 215 City/State/Zip OaWffixVM1946D7 CONSTRUCTION WORK TO BE PERFORMED: *Note: Of isite BoringsNVejls Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t MONITORING _ HOLLOW STEM BORING DEPTH 50 feet bits ❑BOLTEOTRAFFIC BOX ❑STOVE PIPE [I EXTRACTION(VaporMaler) .0 HAMMERIDRIVEN DR.OF BOREHOLE flinches ❑MULTIPLE CASINGS❑MILK TI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS ASTM Schell 80 TYPE OF CASING: ❑STEEL VC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING [I Yes 0 Boring Dia: flinches Casing Dla: 2Inches _Casing Depth: ❑ INJECTION(Nsooss.ozone/ ❑ HANDAUGER GROUTSEALDEPTH 3 nfeetbv, TREMIE TYPE TO BE USED: []AUGERS ❑ROSE IPE ❑ OTHER _ 1-1 OTHER: GROUT SEAL PUMPED? 'es ❑No (Note:Maximum Freefell Depth is 30 Ft) WELUSOILBORINGIDs f GROUT SPECIFICATIONS Neat nnent(M lb ba915-10 gal water) DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMETER of 90 inches to depth of 3 feet WELL IDS MM.See attached Wore Plan for Locations. RECROW'^To depth of 3-20 feet below surface '` wtll +o verf `� o GROUT SPECIFICATIONS Neat cement(94lb bag/5-6 gal water) ❑ EXPLOSIVES From to feel below surfa f.I�Ydue{ ` TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ®PIPE ❑ MUSHROOM CAP ❑3 feet below surface or, feet bell aSUlTace if>3 iset� COMMENTS: �tt - () �-r� � JY/�- �y r h-o'%V q -,s/ZdZ c (N ! to -e. '9 �Ql�tlr Stlwr�2 raK+ lh o 012 l`0 m1 I hereby certify that I am authorized to complete this ap Iicatirm, and that the work will bdkdDno in accordance with //11 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. ,,,e%;,_„ �(e� Wto Signed Q4a4�ae� Title/Company Wbod. Print Name Ja son Reeder Date wt22 4EPARTMENT USE ONLY /Application Accepted By: ate Issued: 22 Grout Inspection By/Dates: Destruction Inspection By/Dates: 4 D Facilit /Site Information FA Name p r O ra.fie I FA Address I FA# 00I g PR# FA PE -ZCi O WP Reviewed By Work Plan Date b'- ❑C-57 C-57Authorization for Other toy Sign Permit ❑Workers Comp ❑Workers Comp Walver ❑Encreachmenl Permit ❑Access Agreement ad Agency AWoyal FR COMMENTS/ ONDITIONS: Ma ln-�A ir01 0- d P au s � wij�- VPeR Lvi1je- ' e ( & Iok � yri � Ugor (AM i S AI f 6, WP TYPE PE I SC I FEE INFO JAMT RIENUTTED1 CHECK# I RECV'D BY I DATE I WELL PERMIT# I INVOICE# Permit IFlot 3(1 $15 CL 1 InI �.8 W D + 3-/O r 1868 E. Hazelton Avenue I Stockton, Cal ornia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2"104 04-07 Site Mitigation Well Permit Application