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cMa on len <br />t I am authorized to complete this application and that the work will be done In accordance with <br />n County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Principal Engineer/Dudek <br />Date 04/23/2019 <br />I hereby <br />Signed <br />Print Na <br />Destruction Inspection By/Dates: <br />------17 Grout Inspection By/Dates: Neele.evi"Alirre- r -//0 /// 1 <br />Application Accepted By: Date Issued: Si II/C) <br />PEPARTMENT USE ONLY <br />SAN ,JOAQUIN <br />COUNTY <br />Egror",, <br />Greotness grows <br />Environmental Health Department <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 1624 East Alpine Avenue <br />Cross Street West Ln <br /> <br />City/State/Zip Stockton/CA/95204 Phone 510-938-7038 <br /> <br />APN 117-080-06 <br /> <br />Property Owner* Pardeep Sooch <br />Address 1079 Yosemite Ave <br /> <br />Phone 510-938-7038 <br />City/State/Zip Manteca, CA 95336 <br /> <br />License# 938110 Exp. 9/30/19 <br />city/State/Zip W. Sacramento, CA 95691 <br />License* Phone 760-479-4130 <br />City/State/Zip Encinitas/CA/92075 <br />C-57 Contractor Cascade Drilling <br />Address 3000 Duluth St. <br />Consultant/Sub-Contractor Dudek <br />Address 605 3rd Strut <br />Phone 916-638-1169 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br /> <br />El EXTRACTION (Vapor/Water) <br />El SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION paw Spam. 07onel <br />OTHER <br />WELU SOIL BORING 1Ds <br />NUMBER INSTALLATION TYPE <br />I=1 HOLLOW STEM <br />El HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GPI CPT) <br />HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? El Yes ID No <br />GROUT SPECIFICATIONS <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: I=1 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth Is 30 Ft) <br />El BOLTED TRAFFIC BOX El STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: El STEEL 0 PVC El OTHER <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs B_i <br />GROUT SPECIFICATIONS Neat Cement (94Ib bag/5-6 gal water) <br />TREMIE TYPE TO BE USED ID AUGERS U HOSE csi PIPE <br />DESTRUCTION METHDOIAltEICTEHREcofk ALL THATAPPLY) <br /> <br />OVER-BORE inches to depth of 57 feet <br />NPRESSURE GROUT To depth of 57 feet below surface <br /> <br />O EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 03 feet below surface or_ feet below surface if >3 feet <br />COMMENTS: <br />Facility/Site Informatl <br />FA Name rrf tA.6.re- Leoss--VY.A1 FA Address 1(0 2,e..1 e _merit, ANAL., FA# PR# <br />arC.4 LAI 01— <br />FA PE 25351 WP Reviewed By 1.— - X <br />01 ZS-2-444 <br />Work Plan Date k ( So tcl <br />El 0-57 Er6"-57 Authorization for Other to Sign Permit 15K‘rker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement Effe'aid Agency Approval PIER <br />COMMENTS/CONDITIONS: (s,,,,,,Jr- ...IA— ..e......-1/4-- No e...&...k- cpe-41 . .. <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK* RECV'D BY DATE WELL PERMITS INVOICE* <br />Permit vi, 0 2 31) $152x <br />41 I 52.- 10942,SW LX SIVI tcl k-J-CoJ 3 4) S1 3 <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />7)21 0'5 $2,) (5)- 3 1.163' G10542,5% C 11 I1'1 ARO crosyl