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i U N <br /> i4"� `°? SANaJOANIN <br /> c0U NTY— Environmental Health Department <br /> �gLrv/ Greatness grows here. <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 Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 2417 N West Lane City/State/Zip Stockton,CA P Phone 209.401.5439 <br /> Cross Street Klinger Road APN 117-090-07 <br /> Property Owner' Joseph Rokoszewski Phone 209.401-5439 <br /> Address 2417 N West Lane citylStatelZip Stockton CA 95205 <br /> C-57 Contractor Environmental Control Associates License# C57#696970 hone 831-662-8178 <br /> Address 3011 Twin Palms Drive City/State/Zip A tos 003 <br /> Consultant/Sub-Contractor Hydrogeologlcal Associates License# P #729 CH # 1 Phone 916-761-3700 <br /> Address 3230 Arena Blvd,#245-373 City/State/Zi Sa ram of A 958 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: O#sfte Borings/Wells RequjtesA ce Agr rr�(set now chmentPermits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIO v <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10-15' ❑B L DTRAF X ❑STOVEPIPE <br /> ❑ EXTRACTION(Vaporfwaler) ❑ HAMMERNRIVEN DIA.OF BOREHOLE 2' ❑ LE GS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS E F I : STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING 7 ® PUSH POINT(GPI CPT) CONDUCTORCASING Yes ❑No 'ng all Casing Dla: Casing Depth: <br /> ❑ INJECTION(N,Soame Dmnel ❑ HANDAUGER GROUT SEAL DEPTH TR ETO BE USED: ❑AUGERS ❑ HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMP ❑Yes No (Note. a)imum Freefall Depth is30 Ft) <br /> WELL/SOIL BORING IDs SB-1 - SB-7 GROUTSPECI NS <br /> DESTRUCTION WORK TO BE PERFORMED: Si UC N METHOD: CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED ❑ 0 E DIAMETER of inches to depth of_feet <br /> WELL IDs S RE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS EX OSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑3 feel below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> thereby certify that I am authorize o compl a this application and that the work will be done in accordance with <br /> C/ S Joa Iin County Or nance Co and Standards, and all other applicable California laws. <br /> Signed Title/Company Principal Hydrogeoloaist Hydroneolooical Assoc <br /> Print NameThomas E.Ballard Date 914117 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: 3 / <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Date <br /> Facflit ISfte Information <br /> FA Name �L (,� FA Address <br /> FA PE - WP eviewed By v Work Plan Dale ' / 1 <br /> C-57 ❑G57Authoiz80onkrOlhKt0 Sgn Permit workers Comp LJ <br /> ❑Workers Oompwaiv/er ❑Encroachment Permit ❑"Access�Agreement ❑Lead�fe�cy Approval ❑ MFR <br /> COMMENTSICONDITIONS: �(Z' /y�„�� be-- r .a-C�-V- Cvsfv-Q�-- w'cxj • <br /> WP TYPE P SC FEE INFO AMTREMITTE151 CHECK# I RECV'D BY DATE I WELL PERMIT# INVOICE# <br /> �iu�' 313 1 s - !off N� 13 Pf 00 '373 ! <br /> 1868 E. Hazelton Avenue I Stockton, Ca ifornia 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.corn <br /> itD 29-01 09-0105 S ite Miti9 .on ,I- calbn <br />