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SA N .J OAQ U I N Environmental Health Ty`enent L. :`. C O U N T Y-- ti,�q�, P Greatness grows here t'nr� Al AUG Z z��9 SITE MITIGATION WELL & BORING PERMIT`APPWAA� 1, E.At For Wells and Boring9 s Used for Contaminant Investi ations and Remediat 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 1423 Bradford Street City/State/Zip Stockton,California 95205 Phone Cross Street N.VVlson Way APN 117-150-19 Property Owner* Surinder P.Singh Phone (209)337-5620 P Address 930 N.VVilson Way (v A 30 City/State/Zip Stockton California 9 205 C-57 Contractor Cascade Drilling License# 938110 R„xI '4 1301jq Phone (916)638-1169 Address 13000 Duluth Street City/State/Zip West Sacramento,CA 95691 Consultant/Sub-Contractor Intertek PSI License# Phone (510)4 34-9200 Address 4703 Tidewater Avenue,Suite B City/State/Zip Oakland,California 94601 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 to 40' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) _ _❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE _ _❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes El No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs Geoprobe(GP) GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED N/A Q OVER-BORE DIAMETER of inches to depth of feet WELL IDs Li 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: �11 ereby certify that I am authorized to complete this application and that the work will be done in accordance with aquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company G Print Name �L O 9 Date O PARTMENT USE ONLY a p Application Accepted By: LAIDate Issued: Grout Inspection By/Dates: M Destruction Inspection By/Dates: Facilit /Site Information FA Name �� 8 v ( t 11 FA Address 9x-23 -gra-44 FA# OO Z� PR# FA PE 2q 5 v WP Reviewed By Work Plan Date ❑C-57 1%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: , iC� u roll t�'Qp r a.� �S i K�� w' 1 n �-d 1 ! ,Gc3-SQ �n oJ,- r +I -t- Z Hoary rrgAik 6y Eh.S iolarm;+ jz(1 6:1610, �5 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Z 31 $152x �.) CO Set ecO 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 n w�, �M Site Mitigation Well Permit Application