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6 a <br /> S A N yJ 0 AQ U I N Environmental Health,Qgpartment <br /> COUNTY II��©rr E���D <br /> l <br /> SITE MITIGATION WELL & BORING PERMIT APPLIClkTIO 4 0510/? <br /> For Wells and Borings Used for Contaminant Investigations and Reme �Al <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED R't'fITSFRL C UN <br /> 48 Hours Advance Notice Required For All Inspections ES <br /> Application Is hereby made to San Joaquin Courtly fora permit to construct andlor 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 1503 E.March Lane cltylstate2lp Stockton,CA 95201 Phone <br /> Cross street West Lane APN 096-140-38 <br /> Property owner Focus Real Estate LLC. Phone <br /> Address 3882 Toomes Rd, citylstaterzip Modesto,CA 95358 <br /> C-57 contractor Gregg Drilling&Testing, License# 485165 Phone 925-313-5800 <br /> Address 950 Howe Road City/State/Zip Martinez,CA 94553 <br /> consultant/Sub-contractor ATC Group Services LLC License# Phone 209-579-2221 <br /> Address 1117 Lone Palm Avenue,Suite 201B cltylstatelzlp Modesto,CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M MONITORING 1 ❑ HOLLOW STEM BORING DEPTH 65 ft. IS BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERCRIVEN DIA OF BOREHOLE 5in. ❑MULTIPLE CASINGS❑MULTI-LEVELWEIL CASING DIA <br /> ❑ SOILVAPORPROSE ❑ MUD ROTARY CASINGTHICKNESS Scn.4U TYPE OF CASING: ❑STEEL ®PVC ❑OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT'(GP/CPT) CONDUCTORCASING ❑Yes ®No Some Dia: Casing Ola: Casing Depth: <br /> ❑ INJECTIONeiaovw.omwl ❑ HANDAUGER GROUTSEALDEPTH 45 fr. TREMIE TYPE TO BE USED: ®AUGERS El HOSE ❑PIPE <br /> ❑ OTHER �, ❑ OTHER: GROUT SEAL PUMPED? EI Yes 91 No (Note:Maximum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs [yluyW]%, 116 GROUT SPECIFICATIONS neat cement <br /> i <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED L]OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of,feet below surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES From_-to_feet balm surface <br /> TREMIE TYPE TO BE USED [I AUGERS HOSE 0 PIPE ❑MUSHROOM CAP ❑3 feet below surface or feat belay surface If>3 feet <br /> COMMENTS: <br /> 1 hereby cordty that I am authorized to complete this application and that the work will be done In accordance with <br /> Si oaquln County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed „-r Title/Company <br /> a Print Name se-GUkm Date (7ilOr-1�1� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: to Issued: 241) <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Date . <br /> Facilit ISIte Information�r <br /> FA Name \ '�� FA Address 7 n� .G / FA# /iT PR# Q gil <br /> FA PE .5 <br /> 0 WP Reviewed By (N V r- V�WJork Plan Date <br /> C-57 0C-57 AuthImumon for Other to Sign Permit MarkersComp ❑Workers Comp Walter ❑Encroachment Peenll seas Agreement atl ABe YApprov FR <br /> OMMENTSICONDITIONS: r' <br /> jWPTYPEj PE I SC I FEE INFO TREMITTED CHECK#I RECV-D BY I DATE I WELL PERMIT# INVOICE# <br /> Permlt I Zj O $152 X 7 <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 49,010841-17 Sae Mitigation Well PemY!Application <br />