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ip as SA N J OAQ U I N Environmental Health Department "----_COUNTY _v_"- `. `' Greatness grows here SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 1111 Navy Drive i City/State/Zip Stockton _ Phone 209-948-0129 Cross street Argonaut Street APN 163-260-07 Property Owner* Tacky&Sons Poultry LLCPhone 559-443-2700 Address 2020 S.East Avenue City/State/Zip Fresno,CA 73721 C-57 Contractor TEG License# 706560Phone 916-853-8010 Address 11350 Monier Park Place City/State/Zip Rancho Cordova,CA 95742 Consultant/Sub-Contractor Geographic Services Inc. License# Phone 916-385-0202 Address P.O.Box 4517+ Y� City/State/Zip Citrus Heights,CA 95611 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20'-30' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 5 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER Q SOIL BORING ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soame ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: []AUGERS ❑HOSE❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes❑No (Note:Maximum Freefall Depth Is 30 Ft) WELL!SOIL BORING IDs SGT,SG2,SG3,SG4,SGS,GW1 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Direct push boringshemporary soil gas probes at locations to 5'for soil gas sampling. At 1 location(GW1 boring will be installed to 20'to 30'for groundwater sampling) I hereby,certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. c I Signed �'' , Title/Company C'6 &c S h_ r;r ,x, 3 A Print Name �, ,I �r•� ( � ��cis Date// / f�- DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Da s: Facility/Site Information FA Name ^ (1n. FA Address ;/% f Q(-- FA# e' 'l `I (. " PR# E FA PE WP Reviewed By Work Plan Date 1 ! / G57 [I C-57 Authorization for Other to Sign Permit orker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead A ncy Approval FR COM E_NTS/CONDITIONS:,, alb SCS N ,� ��i,4- �.I�'f-�, d`.�°.�-dJ� eru•�.c�; iJ�„�w ca� �I(-c..� ' rw�,�`e� �� cc;�.�a:�v► � WP TYPE PE SC FEE INFO AMT REMITTEIDj CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x l i U�� IN?��3 OG 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 1468-3420 1 F 209464-0138 1 wwvv.sjcehd.com EHD 2M1 08411-17 Site Mitigation Well Permit Application