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I t � SAN�JOAQUIN �Ii\`(:: ' � —couNTv— Environmental Health Department 1\0 s`% Greotness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION OCT 13 RECD 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. CitylState/Zip Stockton CA Phone 209.466-4725 Job Address 2413 N West Lane p APN 117-090.07 Cross Street Klinger Road phone 209-066.4725 Property Owner` Sue Rokoszewskl Address 2417 N West Lane City/State/Zip Stockton, CA License# C57#695970 Phone 831.662.8178 C57 Contractor Environmental Control Associates City/State/Zip Aptos CA 95003 Address 3011 Twin Palms Drive phone 916-781-3700 ConsultantlSub•Contractor Hydrogeological Associates License# PG#7299,CHG#961 3230 Arena Blvd,#245.373 City/State/Zip Sacramento,CA 95834 Address CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsAells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS [I MONITORING ❑ HOLLOW STEM BORING DEPTH 10-15' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vaporfwaler) ❑ FWAMERIDRIVEN DN.OF BOREHOLE 2' ❑MULTIPLE CASINGS❑MULTI{EVEL WELL CASING DIA ❑ SOILVAPORPROSE [I MUD OF CASING: ❑STEEL ❑PVC El OTHER MUD ROTARY CASING THICKNESS Casing Dia: Casing Depth: ❑ SOIL BORING 4 ® PUSH POINT(GPI CPT) CONDUCTOR CASING [I Yes []No going REMIETYPETO BE USED: [I AUGERS ❑HOSE ❑PIPE El INJECTION(AkSW 0 ) ❑ HANDAUGER GROUTSEALDEPTH ❑ OTHER [IOTHER: GROUT SEAL PUMPED? ❑Yes ONO (Note:Maximum Freefoll Depth is 30 Ft) WELU SOIL BORING IDS Se-1 SB-7 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPIL #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of_feet WELL IDs ❑ PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From lo_feel below surface GROUTEMIE TYPETO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑ MUSHROOM CAP ❑ 3 feet below surf ace or feel below surface If>3 feel COMMENTS: I her .ertify that I am authorized to complete this application and that the work will be done in accordance with San J adDin County dinance Codes and Standards, and all other applicable California laws. Title/Company Principal Hydrogeologist IN drogeolonical Assoc Signed Print NameThomas E. Ballard Date 914117 DEPARTMENT USE ONLY O ate Issued: Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: \ r 1 Facilit (Site Information PR# OC2z3Eo FA Name a L n I " FA Address ?Lr ' 'I �- FA# (� FA PE '9-n WP viewed By L Work Plan Dale C.57 ❑C57 Authorization far Other to Sign Permit ElWojkersCoMP ❑Workers Camp Waiver ❑Enaoschmenl Permit ❑AccessAgre/ement ❑Lead Agency Approval FR COMMENTS CONDITIONS: I rw—SL 1 Q,r,1,/C�1t�^'-e`. �` S-i� M'Aim 1'v't-2.4tJ�' a( Vr' F� wr'J ^ 1 1 WP TYPE PE SC FEE I FO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# per Z40`` 313 IS2 3 I � 103/'i ru- 11P00 3-7 r l-O 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209 468-3420 i F 209 464-01 M8 auoewel s ceh a om site Eno 29,01 0a-01-17