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SAN.-,JOAQUIN Environmental Health Department COUNTY Grectne,s grc,,,� , 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 2245 W. Charter Way City/State/Zip Stockton, CA 95206 Phone (209)337-0055 Cross Street Tillie Lewis Dr. APN 163-36-017 Property Owner* Raymond Investments Phone (209)466-8604 Address 817 S. Center Street City/State/Zip Stockton, CA 95206 C-57 Contractor Cascade Drilling License# C-57#938110 Phone (916)639-1169 Address 3000 Duluth Street City/State/zip West Sacramento CA 95691 Consultant/Sub-Contractor Condor Earth License# 938110 Phone (209)234-0518 Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYIE OF WELLIBORING NUMBER NSTALLATION TYPE CONSTRUCTION SPECIFICATIONS J MONITORING 1 HOLLOW STEM BORING DEPTH 25 feet VOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 Inches ❑MULTIPLE CASINGS❑MULT EVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS�ches_ / TYPE OF CASING: [I STEEL NPVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes Y No Boring Dia: Ca g Dia: Casing Depth: ❑ INJECTION(Air Soame,ozone) ❑ HAND AUGER GROUT SEAL DEPTH 2.5 fe_er TREMIE TYPE TO BE USED: AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑YeS N0 (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs MW-6 GROUT SPECIFICATIONS 94lbs cement/5-6 gallons of water 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 County Ordinance Codes and Standards,and all other applicable California laws. Signed J-kk�tl- Title/Company PG #6795/Condor Earth Print Name John P. Lane Date 3/20/19 DEPARTMENT USE ONLY Application Accepted By:. Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name h�� FA Address / 1�� PR# lzr+��-„ zsr/��fl,G eoL�e* w Z33 S ®g22 FA PE L94o WP Reviewed By �/� Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: 44�,,l e WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Lgol 3/3 $152 x / j//Sa•a0 ds"5I/ ,1141 5A,3/19 0394 41,r 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EH 29-01 08-01-17 Site Mit ion Well Permit Application t'vP z,V3 �y� 15240 xr3 J ysG•u� /f�/ M9 s/.�//9 390479CIO 3551