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SKJ OAH I N Environmental Health Department <br /> � COUNTY <br /> °'q Ir.o V, Greatness grows here. <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 Count ell Standards. <br /> Job Address 1423 Bradford Street City/State/Zip Stockton,California 95205 Ph e <br /> Cross Street N.Wilson Way APN 117-150-19 <br /> Property Owner* Surinder P.Singh Phone (209)337-5620 <br /> Address 930 N.Wilson Way 6N1 City/State/Zip Stockton California 952 <br /> C-57 Contractor TEG Northern California License# 706568 e I Z I Phone (916)853-8010 <br /> Address 11350 Monier Park Place City/State/Zip Ranch Cordova lifornia 95742 <br /> ConsultantlSub-Contractor Intertek PSI License# Phone (510)4 34-9200 <br /> Address 4703 Tidewater Avenue,Suite B City/Sta /zip Oakland, lifomia 94601 <br /> CONSTRUCTION WORK TO BE PERFORMED:"Note: sANells Re ui Acce reements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CO TR TI N S ECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORIN\TCK <br /> ;V-5'GP-1 ' B TED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ElHAMMER/DRIVEN OE LE 2 inch ULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA <br /> ® SOIL VAPOR PROBE 5 ❑ MUD ROTARY A ESS N/A PE OF CASING ❑STEEL❑PVC ❑OTHER <br /> ® SOIL BORING 2 PUSH POINT(GP/CP ON UCTOR CASIN Yes N Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air sgxge.Ozonel ❑ HAND AUGER 0 T SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUTS PUMPED9 ❑ es No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL SOIL BORING IDs Soil Vapor SV &Geo robe GP ROUT SPE IC TIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DE RUCTION METHOD: CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED N/A OVER-BORE r S, pIAMETER of inches to depth of feet <br /> WELL IDs P SSURE 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 Jam+ t All f i r'e-s vafdi^ pra) M q0- <br /> o►� 1 /�d ttn�o i( �v r� . h2 a 6 /l9 <br /> rtify that I am authorized to cp.rhplete this application a d that the work will b do accordance w h <br /> oaquin County Ordinance Codes and Standards,and all other appli Wble California law <br /> Title/Company Wv 1 <br /> Print Nam Date <br /> PARTMENT USE ONLY /31 Z-7 G9 <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information <br /> FA Name FA Address FA# ZS PR#O i K100 <br /> FA PE 2,q WP Reviewed By Work Plan Date <br /> CIC-57 -57 Authorizaf for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMM NTS/ ONPITIONS•Z (� a 40% w M e W i►t <br /> IN l? -�f/!l2 ver - Z Aours -(fit•s �2.riihr* h� p2ya hll// 62 Icd� <br /> 'bi <br /> blt <br /> WP TYPE PE SC FEE INFO AMT REMITTED1 CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit Z Wr 5 13 $152 x 2 O 369 Z v <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2MI 08-01-17 Site Mitigation well Permit Application <br />