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r <br /> S A N J OAQ U I N Environmental Health Department <br /> COUNTY- RECEIVE® <br /> �'14ront""� Greatness grows here.SITE MITIGATION WELL & BORING PERMIT APPLICAMMa�T W 2018 <br /> For Wells and Borings Used for Contaminant Investigations and Rd"W44VA-HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> 48 Hours Advance Notice Required For All Inspections <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 till Nny M+e, citylstatelzip Stowon Phone 209-948-0129 <br /> Cross Street Argonaut Street APN 163-260.07 <br /> Property Owner* tacky&Sons Poultry LLC Phone 559-443-2700 <br /> Address 2020 S. East Avenue City/StatelZip Fresno, CA 73721 <br /> C-57 Contractor TEG License# 706568 1 Phone 916-853-8010 <br /> Address 11350 Monier Park Place City/State/Zip Rancho Cor ova, CA S7742 <br /> ConsultanUSub-Contractor Geographic Services Inc. License# Phone 916-385-0202 <br /> Address P.O. Box 4517 CilylStatelzip Citrus ig A95611 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: OUsite BoringslWells Requir s greements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M MONITORING 1 IN HOLLOWSTEM BORING DEPTH 20.-W OLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapw/Waler) ❑ HAMMER/DRIVEN DIA.OFBOREHOLE T MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ® SOILVAPORPROBE s ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑ o Boring Dla: Casing Dia: Casing Depth: <br /> ❑ INJECTION IAIr eaeae.0zonel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED No (Note:Maximum Freefall Depth is 30 FQ <br /> WELD SOIL BORING IDs 8ct,8c2.SG3.SGe,sc5,GWt GROUT$PECIFI TION <br /> DESTRUCTION WORK TO BE PERFORMED: STRUCTION METHOD, <br /> CHECKALLTHATAPPLY <br /> #WELLS TO BE DESTROYED a [I OVER-BORE DIAMETER of inches to depth of feel <br /> WELL IDs Sol.sot,so3,$G4,scs,Gwl ❑PRESSUREGROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIP ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel <br /> COMMENTS: <br /> Direct push borings#emporary soil gas probes at ti a to F for soil gas sampling. At 1 location(GWt boring will be installed to 20'to 30'for groundwater sampling) <br /> I hereby certify that I am authorized t complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordi ance Codes and Standards, and all other applicable California laws. <br /> Signed Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dales: <br /> Facillt /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Dale <br /> ❑C57 0G57Aulho' tbn for Wier to Sign Permit ❑Workers Camp ❑Workers Comp Wahrer ❑Encroachment PemlB ❑Access Agreement ❑Lead AgencyApproral ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE I SC I FEE INFO JAMT REMITTED CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2"1 09-01-17 Site Mitigation Well Permit Application <br />