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SAN.J O A Q U I N Environmental Health Department <br /> --- COUNTY <br /> ! C�rcatn-ens grattis r,- r<. <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 2245 W. Charter Way City/State/Zip Stockton, CA 95206 Phone (209)337-0055 <br /> Cross Street Tillie Lewis Dr. APN 163-36-017 <br /> Property Owner' Raymond Investments Phone (209)466-8604 <br /> Address 817 S. Center Street City/State/Zip Stockton, CA 95206 <br /> C-57 Contractor Cascade Drilling License# C-57#938110 Phone (916)639-1169 <br /> Address 3000 Duluth Street City/State/zip West Sacramento, CA 95691 <br /> Consultant/Sub-Contractor Condor Earth License# 732026 Phone (209)234-0518 <br /> Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA 95206 <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 15 and 30 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> OILVAPOR PROBE UD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> SOIL BORING 2 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Ca g Dia: Casing Depth: <br /> ❑ INJECTION(air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 2.5 fear TREMIE TYPE TO BE USED:VAUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes M N0 (Note:Maximum Freetall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs B48A and B48B GROUT SPECIFICATIONS 94lbs cement/5-6 gallons of water <br /> 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 /> 1 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 J-kA-�(.R Title/Company PG#6795/Condor Earth <br /> Print Name John P. Lane Date 03/20/19 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: 1' - Date Issued: S 2311 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: j9$&,- I`/N 7- 7-11 <br /> Facilit /Site Information <br /> FA Name �ntr ,/_lei .,P / FAAddress Z�9/s A1• �gr6eY Wa FA# pO233tfq PR# C>Sy0J-2 <br /> FA PE p7v2-444 t'� (lt�.>~ WP Reviewed By N�sE Work Plan Date <br /> ❑C-57 ErC-57 Authorization for Other to Sign Permit ETINorker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit RrAccess Agreement ❑Lead Agency Approval G?IOIFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit L1, 3►3 $152x 2- y H•uU /1*/ <br /> ,,A 5-43119 ,� 396yy <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 29-0108-01-17 Site Mitigation Well Permit Application <br /> 14? 1903 5-L3 �� x3 9 S,4&oo jv`3a <br />