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Environmental Health <br /> Ith De artment <br /> SAN 10A UIN a <br /> - _,u N r.,.. <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 Tide,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 14800 West Schulte Road city/statemp Tracy, CA 95377 Phone 510-410-1009 <br /> Cross Street South Lammers Road APN 209-240-23 <br /> Propertyowner' Rob Pennington Phone 916-596-2511 <br /> Address 2600 Capitol Avenue, Suite 430 _city/StatalZlp Sacramento, CA 95816 <br /> C-57Contractor Environmental Control Associates, Inc. License# 695970 Phone 831-662-8178 <br /> Address 3011 Twin Palma nrivP City/State/ZipAptOS, CA 95003 <br /> Consultant/Sub-Contractor Partner ESI License# Phone 510-410-1009 <br /> Address 1017 22nd Ave, Suite 107 city/staterzip Oakland CA 94606 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑ HOLLOW STEM BORING DEPTH 10 to 5',2 to It]BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑EXTRACTION(vammater) ❑ HAMMEIRDRIVEN DIA.OF BOREHOLE 2.5'' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING'❑STEEL❑PVC❑OTHER <br /> ®SOIL BORING 12 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes❑No Boring Dia Casing Dia:_Casing Depth: <br /> ❑INJECTION WrSo"Ozone t ❑ HAND AUGER GROUT SEAL DEPTH TREME TYPE TO BE USED:❑AUGERS❑HOSE❑PIPE <br /> ❑OTHER ❑ OTHER Di rect- GROUT SEAL PUMPED? ❑Yes❑No (14018:Maximum Freefal Depth is 30 Ft) <br /> WELUSOILBORNGIDs Push GROUT SPECIFICATIONS <br /> B1 through B12 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL 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 ❑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: Advance 10 borings to five feet bgs and two borings to 12 feet bgs for soil sampling <br /> only, <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 Y _Title/Company j2vv e- e Y 7 1 <br /> MAI- <br /> Print Name <br /> PrintName v Qj{�,r'V, j&,y)oV\ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: _<<� U <br /> Grout Inspection BylDates- <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# O(j2,4 10kj PR# <br /> FA PE 2^ WP Reviewed By Work Plan Dai 1('0 F <br /> ❑G-57 57 Authorization for Other to Sign Peirnit OKbrkersCorrip ❑Workers Comp Waher ❑Fnmadimenl Pemst ❑Access Agreement ❑Load Agency Approval 1a1FR <br /> COMMENTSICONDITIONS: - �, 3 l { <br /> ,w fIse-� <br /> WP TYPE I PE I SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE WELL PERMIT# I INVOICE# <br /> Permit I Z.Ci&,: 3 13 $152. S .�im ; x 1('109 <br /> 1868 E.Hazelton Avenue 1 Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br /> EHD 29-01 09.01-17 sae Mltip tion well Permlt Appllmhon <br /> •KV413y3 L---X blMI4, S"'Zn9"3 <br />