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off`c' SQN9J0QQ1N Environmental HealthQ� a�r �i�� <br /> —COUNTY— <br /> Greatness grows here. ENI/j <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION/rSER�,F�trH <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 14700 Schulte Road City/State/Zip Tracy, CA g5477 Phone (209)846 <br /> -8269 <br /> Cross street S. Lammers Road APN 209-240-024 <br /> Property Owri Owens-Brockway Glass Container Inc Phone (20g) 8411_ 82sq <br /> Address 14700 SchUlte Road CitylState/Zip Tracy. CA 95377 <br /> C-57 Contractor Grego Drilling License# 485165 Phone (925)313-5800 <br /> Address 950 Howe Road City/State/Zip Martin A 94553 <br /> Cons ultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED-"Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLISORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N <br /> [X MONITORING 1 CR HOLLOW STEM BORING DEPTH 85 feet CXBOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(vapor/water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8-Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2-Inch <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS SChed 40 TYPE OF CASING: [I STEEL tH PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes RNo Boring Dia: Casing Dia: Casing DeA: <br /> ❑ INJECTION(Aramme.ozane) ❑ HAND AUGER GROUT SEAL DEPTH 60 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IA PIPE <br /> Cl OTHER ❑ OTHER: GROUT SEAL PUMPED? (X Yes ❑No (Note:Maximum I'Mefatl Depth is 30 Fry <br /> WELL/SOIL BORING IDs MW-5R GROUT SPECIFICATIONS_ Standard 16 sack mix with no more than 4% bentonite <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL 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 feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company CKG Environmental, Inc. <br /> Print Name Christina Kennedy Date 10/24/17 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Fac!lit /Site Information <br /> FA Name FA Address FA# p <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑tC.57D C-57 Authodzatbn for Other to Sign Permit <br /> OW <br /> Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Awm Agreement ❑Lead Agency Approval ❑MFR <br /> COMME NTS/CON DI TI ONS: <br /> WP TYPE PE sCFEE INFO AMT REMITTED CHECK# RECV C BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2M1 08-01-17 <br /> Site Mitigation Well Permit Application <br />