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o nurry <br /> �7ct\ SAN���OAQUIN Environmental Health Department <br /> i -COUNTY— <br /> RECEIVED <br /> ,p EIVED <br /> ' 6001K�' Greatness grows here yy_ <br /> SITE MITIGATION WELL & BORING PERMIT APPLICA W 2018 <br /> For Wells and Borings Used for Contaminant Investigations and llthl"OWMALHEALTH <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 tttl NavyDrive City/State/Zip Stockton Phone 209-948-0129 <br /> Cross Street Argonaut Street APN 163-260-07 <br /> Property Owner* Zacky&Sons Poultry LLC Phone 559-443-2700 <br /> Address 2020 S. East Avenue City/State/Zip 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 742 <br /> Consultant/Sub-Contractor Geographic Services Inc. License# Phone 916-385-0202 <br /> Address P.O.Box 4517 City/State/Zip Citrus ig CA 95611 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Requir s greements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION S�0! <br /> IFICATIONS <br /> ❑9 MONITORING 1 ❑� HOLLOW STEM BORING DEPTH ' OLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE MULTIPLECASINGS❑MULTI-LEVEL WELL CASING DIA <br /> 9 SOIL VAPOR PROBE 5 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑ o Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH L TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED, ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs SG1,SG2,SG3,SG4,SG5,GW1 GROUT SPECI7TIONS <br /> DESTRUCTION WORK TO BE PERFORMED: STRUCTION METHOD: CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED 6 ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDS SG1,SG2,SG3,SG4,SG5,GW7 ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS Z Z ❑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 feet <br /> COMMENTS: <br /> Direct push borings/temporary soil gas probes at Ztis <br /> o 5'for soil gas sampling. At 1 location(GW1 boring will be installed to 20'to 30'for groundwater sampling) <br /> I hereby certify that I amauthorized t complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordi ante 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: z <br /> Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authori2ation for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# 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 29-01 08-01-17 Site Mitigation Well Permit Application <br />