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i <br /> °P• • • . <br /> " ' y SAN JOAQUIN COUNTY <br /> _' ENVIRONMENTAL HEALTH DEPARTMENT <br /> y• <I <br /> VON!!4 1 a 4 5. 614 4 1868 Hazelton Avenue , Stockton , CA 95205 -6232 <br /> i� % FORS Telephone : ( 209) 468 -3420 Fax: ( 209 ) 468-3433 Web: www . socehd .com <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 /> 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 1700 North Chrisman Road 22 City/State/Zip Tracy/ CA / 95304 Phone <br /> Cross Street East Paradise Road APN 25002093 <br /> PropertyOwner* Manuel Toste Rocha Phone <br /> Address 26469 S Macarthur Drive , Tracy , CA 95376 City/State/Zip Tracy / CA / 95304 <br /> West Coast Exploration ( � ��/�(� p, � 9 2099857541 2099857591 <br /> C-57 Contractor P ( r + N icense# Phone <br /> Address P . 0 , Box 133 /City/State/Zip Escalon , CA , 95320 <br /> Consultant/Sub-Contractor ENGEO , Inc � (yt,uj License# Phone 2096847611 <br /> Address 17278 Golden Valley Parkway City/State/Zip Lathrop / CA / 95330 <br /> CONSTRUCTION WORK TO BE PERFORMED : " Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> In MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 20 t.R / ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br /> ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA, OF BOREHOLE flinch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0. 15 in TYPE OF CASING: ❑ STEEL ❑x PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes ❑ No Boring Dia: 4 Casing Dia: `21 Casing Depth: 201 <br /> ❑ INJECTION ft Soame. ozone) ❑ HAND AUGER _ GROUT SEAL DEPTH '1 Ioo1 TREMIE TYPE TO BE USED: [IAUGERS ❑ HOSE ❑ PIPE <br /> Solis - flight <br /> El OTHER ® OTHER: GROUT SEAL PUMPED? ❑ Yes © No (Note: Maximum Freefall Depth is 30 Ft) <br /> WELU <br /> SOIL BORING IDS 1 -pQ, 1 -P2 GROUT SPECIFICATIONS Cement <br /> UGAo -�j' V <br /> G { yy { DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) <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 /> n Joaquin ounty Ordinance Codes and Standards, and all other applicable California laws . <br /> Signed „ Title/CompanyENGEO, INC. <br /> Print Name TayforStrack Date 1/1er2017 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: 6N� Date Issued : '�✓7®�� 7 f <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 123117 <br /> ❑ G57 57 Authorization for Other to Sign Permit ❑A�Workers Comp ED4orkeft Comp Waiver ❑ Encroachment Permit ffAccess Agreement ❑ Lead Agency Approval 93FR <br /> COMMENTS/CONDITIONS : <br /> SR TYPE PE I SC FEE INFO JAMT REMITTED CHECK# RECWD BY DATE SERVICE REQUES,TT## INVOICE# <br /> Permit 2 ) O y Y(,7 $ 139 x 2, 671f <br /> �✓� �7 SPoo 7� -9 / <br /> 29v3 5Z3 / 7 -1// 7 ' U2315001669 � <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />