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I <br /> SAN f OAQUIN Environinental Health Department <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 /> 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 2532 Dorset Lane City/State/Zip Tracy, CA 95377 Phone Rob M.u(Arcadis)9252a6J3T7 <br /> cross street Blackbird Court APN 238-300-05 <br /> Property Owner` Mr. and Mrs. Fisher Phone <br /> Address 2532 Dorset Lane citylstate/zip Tracy, CA 95377 <br /> C-57 Contra r1 Peneeore ( F-1,111 r License# 906899 Phone (530) 661-3600 <br /> Address 220 N. East Street Citylstate/zip Woodland, CA 95776 <br /> Consultant/Sub-Contractor Rob Moniz-Arcadis License# Phone 925.788-7377 <br /> Address 2300 Clayton Rd Suite 400 City/state/zip Concord CA 94520 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offshe BoringsANells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MUNITORING ❑ HOLLOWSTEM BORING DEPTH loft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporM'a[eg ❑ HAMMER,DRIVEN DIA.OF BOREHOLE 3.5 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> X SOIL VAPOR PROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC I(OTHER Teflon tubing <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ANo SoMhg Die: Casing Die: Cssbg north: <br /> ❑ INJECTION(a soarm ozoni IS( HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS 0HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [I Yes 15 No (Note:Maximum Are Mal Depth is 30 Fit <br /> WELL)SOIL BORING IDs B-12 GROUT SPECIFICATIONS Hydrated Bentonite Grout V to 4'9"in <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> It WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSUREGROUT To depth of_feetbelinv surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO RE USED ❑AUGERS ❑ HOSE ❑PIPE El MUSHROOM CAP ❑3 feet below surface or feet belon surface it>3 feet <br /> COMMENTS: <br /> I hereby cerI99 that I am authorized to complete this application and that the work will be done In accordance with <br /> No Joaquin County Ordinance Codes and Standards,and all other applicable California laws. . <br /> Signed Title/Company 44no <br /> Print Name (/ Date /„} ;�•�9 <br /> ARTMENT USE ONLY <br /> Application Accepts By: 2 Dale Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Oates: <br /> Faclllt /Site Information 1 ' �p �1 <br /> FA Name 11 FAAddress � FA# ©o0t'y' PR# D.��go 2 <br /> FA PE ��• Z96� WP Reviewed By ✓� Wak Plan Dele L l ,q <br /> -S7 0C-57 Authorization for Other to Sign Permit ❑Wodkees Comp ❑Workers Comp Waber ❑Encmzchment Peroct ❑Access Agreement ElLead(Agency Approval ❑MAR I <br /> COMMENTS/CONDITIONS/ l *jo(, gyp- to li LI t� <br /> Amy// — T ISI1► -A �1 T N <br />�1 I WP TYPE PE SC FEE INFO A IT REMITTED1 CHECK# I RECV'D BY DATE WEILL PERMIT# INVOICE# <br /> Permit 3 I $152 x (` <br /> �1T JiS� 1 68 F_. HazeIto�kAYenue i Stockton. California 952051 "T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.corn <br /> r F.HD 2ffOf oBOf-17 L� Y��I �O 57"SA M gtim WWWa1 V�pi'ppp4 etim <br /> �t0 � ZQoI 1 ! 8� 55[/(- <br />