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SAN 10 A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness qrows herr. <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 455 11th St. City/State/Zip Tracy/CA/95376 Phone <br /> Cross Street N.MacArther Dr. APN 23337007 <br /> Property Owner* San Joaquin Lumber Company Phone (510)645-1850 <br /> Address 455 11th St. City/State/Zip Tracy/CA/95376 <br /> C-57 Contractor Gregg Drilling License# 485165 Phone (925)313-5800 <br /> Address 950 Howe Rd. City/State/Zip Martinez/CA/94553 <br /> Consultant/Sub-Contractor Terraphase License# Phone (510)645-1850 <br /> Address 1404 Franklin St.,Suite 600 City/State/Zip Oakland/CA/94612 <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10-20'bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE X 31 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air sparge.Ozone) IR HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I31 PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELUSOIL BORING IDs GROUT SPECIFICATIONS Neat cement grout <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed ae4.4� Title/Company Staff II Engineer/Terraphase <br /> Print Name Petra Eber pacher Date 6/22/18 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: to L '/Ald <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address 1'4SS FA# 6,LlU_iZC, .� PR# CSILAz3to <br /> FA PE 3(t 5-p WP Reviewed By L - ' Work Plan Date <br /> El C-57 C-57 Authorization for Other to Sign Permit oftes Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval 4 FR <br /> COMMENTS/CONDITIONS: 'L�{ >to cl--4 \j"(.- eAA S Iry—li'k torr <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit ,L4 13 $152 x -3 y S� L--)t ( 'ZC1 uj r o n 3�q <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-0108-01-17 �, Site Mitigation Well Permit Application <br /> f M0 51,3 $1Szx 3 #Q-&b •-�iclq a gv 1 L1­)( /1-1 '-ko-1 f33 0 <br />