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UTN 'o co N SAN J OAQ U I N Environmental Health Department COUNTY o r! {,rrnlnr<c nrnws hrrP `�i4\11RONMEN(ALHEALTH c,F6 pEphq►TISENCES SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 434 East Martin Luther King Jr. Blvd, City/State/Zip Stockton, CA 95203 Phone Cross Street California Street APN 167-150-310-000 Property Owner` Floral and 99:--L-P-- 13•L E P1 J Phone Address 1155 W. Shaw Avenue:Suite 4,04 P J &x 3 ity/State/Zip Fresno, CA 93711 C-57 Contractor Grega Drilling and Testing License# I ii 4Lt-i'sti Phone Address 950 Howe Road City/State[Zip Martinez, CA 94553 Cons ultant/Sub-ContractorWayne Perry, Inc. License# 300345 Phone 714-826-0352 Address 8281 Commonwealth Ave City/State/Zip Buena Park, CA 90621 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1A MONITORING HOLLOW STEM BORING DEPTH 3n feet g BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE $lini ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 2 inrhes TYPE OF CASING: ❑STEEL W PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes W No Boring Dia: Casing Dia: Casing Depth, ❑ INJECTION(Air Sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: IN AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes IN No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs MW-4 and MW-5 GROUT SPECIFICATIONS Neat Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin unty Ordinance Codes and Standards,and all other applicable California laws. Signed ./tea _ Title/Company ��Oj _�%� /'tf} E<- li1J/4Y/ PE) �y/� - Print Name In//e/1-1y7 boa I'VA Date DEPARTMENT USE ONLY Application Accepted By: / /1 Date Issued: f Grout Inspection By/Dates: li,,(zSY't��.._4_� t Destruction Inspection By/Dates: Facilit /Site Information FA Name �rn^L✓ � � ✓`^Ct, FA Address 3N CA�k �� '� FA# .,J -�� PR# FA PE ?S�f�Y f WP Reviewed By �x Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit 13 Worker Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED C,HfV EC{K# RECV'D BY DATEWELL PERMIT# INVOICE# Permit 2AO' 313 $152x 2 334 3 ,�� L % i ) � `I f tl W,.! p0 ' f 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2 �8-01.17 S-(, I L r Site Mitigation II Permit Application IIIL� s�,�O