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ipSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sacehd.com <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 /> 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 Tile,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Vacant land City/state/Zip Manteca, CA 95336 Phone N/A <br /> cross street Dupont Court APN 221-210-20 <br /> Property Owner' Scannell Properties 220 LLC Phone <br /> Address 800 East 916th Street cityistate/zip Indianapolis, IN 46240 <br /> C-57 Contractor Woodward Drilling License# 710079 Phone 707-374-4300 <br /> Address 550 River Road Citylstatelzip Rio Vista, CA 94571 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 30' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) D HAMMER/DRIVEN DIA.OF BOREHOLE 6' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ISI SOIL VAPOR PROBE 40 MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> [KI SOIL BORING 4 ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes [IND Boring Dia: Casing Dia: Cming Depth: <br /> [IINJECTION(Air Soaae.Ownel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Madmum Freefall Depth Is 30 Ft) <br /> WELLI SOIL BORING IDs GROUT SPECIFICATIONS OAiAv `CJI �'y <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHEOKALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> I here erti t I dt 1 this application and that the work will be done in accordance with <br /> o rdi des and Standards,and all other applicable California laws. <br /> Signed Title/Company Terracon Consultants, Inc. <br /> Print Name SC a Date 6-9-17 <br /> DEP ARTMENTUSE ONLY <br /> Application Accepted By: /v/}j7}Lr A �U6$-0 t7fii A�C..O✓1�. yA�- Date Issue : b/�.�//7 <br /> Grout Inspection By/Dates: _ 9TA�-71 �/��Q,o j/I/J.E�/f tib 6l-ad <br /> Destruction Inspection By/Dates: <br /> Faciits Information <br /> FA Name �,�^�� �f ..1��r 1l FA Address ,jam l 6 FA# �q��O l�� pR# "te� 7 <br /> FA PE .! c�s� WP ReMewed By pt�gy'A, S/tt�n�03ai/✓i k.OYA Work Plan Date <br /> [3 C-57 0C-57 Authnization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waver ❑Emroadarent Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: rnp _ ,_„� C:Ll�..t <br /> SR TYPE I PE SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# <br /> Permit I 2905 -gt3 $139x �3 yt1 llS.'I d /3�r7 1 590011711 <br /> Io <br /> ,r uie3 Sz3 1357 � ;5 �I'I all"Ib� � S(��7�'llY <br /> EHD 29.01 10-26-2015 Site Mitigation Well Permit Application <br />