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t <br /> - ~; SANDJOAQUIN Environmental Healtl ent <br /> . <br /> COUNTY �a ``�LM, EfV <br /> DEC 0 5 2017 (� <br /> SITE MITIGATION WELL & BORING PERMIT APPLIC/k`TP <br /> For Wells and Borings Used for Contaminant Investigations and Reme ENrA(H <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7SERyCEs <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 1209 E. March Lane city/State/zip Stockton, CA 95210 Phone <br /> Cross Street West Lane APN 140-080-03 <br /> Property owner 1 Toward&Barbara Adler Phone <br /> Address 1515 Shasta Drive, Suite 3115 city/state/zip Davis, CA 95616 <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 city/Statelzip Modesto,CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 65 ft. ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/ORIVEN DIA.OF BOREHOLE 2in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: 11 STEEL ❑PVC ❑ OTHER <br /> (M SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING [3 Yes ®No Bodng Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTIONtek s.m l ❑ HANDAUGER GROUTSEALDEPTH 65 R. THEME TYPE TO BE USED: ❑AUGERS ❑HOSE®PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEALPUMPED7 ❑Yes MNo (Note:Maximum Freefall Depth is 30 FQ <br /> WELUSOIL BORING IDs ___CP -2 GROW SPECIFICATIONS neat cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:!CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Inchas to depth of feet <br /> WELL IDs _ []PRESSURE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From—to—feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP 0 3 feel below surface or feet below surface if>3 feet <br /> OMMENTS: <br /> I hereby certify that I am authorized to complete this appllcaUon and that the work will be done In accordance with <br /> S n Joaquin County Ordinance Codes and Standards,and all ot���hUUheer appllcabie California laws. <br /> Signed —Title/Company <br /> �. Print Name rte v145k. Date IZ4614117 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facil /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> 0C-57 ❑C-57 Authorization for Otherto Sign Permit ❑Worker's Comp ❑Workers Comp Walver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval [I MFR <br /> OMMENTSICONDITIONS: <br /> IWPTYPEJ PE I Be I FEE INFO T REMITTEDI CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit 152 x <br /> 1868 E. Hazefton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 4640138 1 www.sjcehd.com <br /> EHD 29-01 0&0147 site M oko wen Peine Application <br />