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SAN J OAQ U I N Environmental Health Department ...r.: COUNTY 't c�c+coa�'�P✓ Greatness grows here. 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 1624 East Alpine Aevenue City/State/Zip Stockton/CA/95204 Phone 510-938-7038 Cross Street West Ln APN 117-080-06 Property Owner* Pardeep Sooch Phone 510-938-7038 Address 1079 E. Yosemite Ave City/State/Zip Manteca, CA 95336 C-57 Contractor Cascade Drilling License# 938110 Exp. 09/30/2019 Phone 916-638-1169 Address 3000 Duluth St. City/State/Zip W. Sacramento, CA 95691 Consultant/Sub-Contractor Dudek License# Phone 760-479-4130 Address 605 3rd Slreel City/State/Zip lincinilns/CA/92075 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Vells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 70.5'& 110.5' ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 10-5/8-inch ODE]MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS SCl/,40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 0-35' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I9PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefat Depth is 30 Ft) WELL/SOIL BORING IDs KS-10&Ki-20 GROUT SPECIFICATIONS_Concrete from 0'-5'bas,High So' en e Grout 5-35'bgs Bentonite chips 35-40'bgs Concret from 0-5'bgs,High Soli ite Grout 5-75'bgs,Bentonite chips 75'_80'bgs A,eq ce o - 0 8 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 —. `` an J quin County Ordinance Codes and Standards,and all other applicable California laws. Signed /_ �" Title/Company Principal Engineer/Dudek Print Name Glenn McMahon Date 7/12/19 DEPARTMENT USE ONLY � /Z Application Accepted By: Date Issued: f/ L:E1 Grout Inspection By/Dates: Destruction Inspection By/Dates: o Facilit /Site Information 'Z` h FA Name FA Address l 6 Z� �* FA# Z��(� PR#CL V- Q FA PE 21 G 7 WP Reviewed By Work Plan Date 1 a yj ❑C-57 657 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/ N ITION27Tl p r��Frf„ims APA) Se°�� 4 �✓ '�a *Q �r o r b�_/` ' efd- in I'K wWAL WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PE T# INVOICE# Permit 0 1� $152 x 3o �, l � ' W V 3 1868 E. Hazelton Avenue I Stockton, California 9 205 T 468w-3420 1 F 209 464-0138 1 _ www.sjcehd.com/EHD29-0108-01-17 �/_/ DMw itionWeP� it licatio rM`Aroi �C j ��