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r I d 41 �L X11 C+� d4 n SAN . E JOAQUIN Environmental - ItD COUNTY � �_ H /aH ., �� ' (_[��,11G� 01'�li11E 11 , Greotness grows here . i- . � ,^. r , fir ' = NT C 6 2019 SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remed (MI NON- REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSLF61 I � � l��l� /� �> HEALTH ME 48 Hours Advance Notice Required For All Inspections FIF NT Applfcation Is hereby made to San Joaquin County for a penrA 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 , 1323 W1 Charter WayDR AAFtfA/ W ¢1� WA) ¢¢� Stockton , CA 952 209-522-4119 Job Address ---- Vfty {ats/Zlp — . _- - _ Phones -------- -_ _ - __. , Cross Stre t S . Stockton St APN 163-230-050 Property Owner' Gertrude A. Bentz Family Trust , Margo Bentz- Ivers , Trustee Phots 209483-7285 Address 4750 Lagoria Rd . _ _ - citylstatemp Stockton, CA 95215-1811 C-87 Contractor Woodward Drilling Licor"M C57 710079 Phone 707-3744300 Address PG BoxW CftylStatNZip Rla Vista, CA 94571 _ ConsuitantlSub-Contractor Ground Zero AnalYEisI Inc. Lk4nu$ Gregory Stahl, PG 5023 _ Phones 209-522-4119 Address 1172 Kansas Avenue cltytstatomp Modesto, CA 95351 _ CONSTRUCTION WORK TO BE PERFORMED: *Note : Offsfte BoringsNVelIs Require Access Agreements or Encroach nent Permits TYPE OF WELLIBORTNO NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MOMTORING _ ❑ HOLLOW STEM BORING DEPTH 5 Fl (1 ), 15 R (2) ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (V8Wfflaw) ❑ IIAMMERARIVEN Mk CF BOREHOLE 2 tKh ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DU ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS __ TYPE OF CASING: ❑ STEEL ❑ PVC 13 OTHER ® SOI. BORING =® PUSH POINT (GPI CPT) CONDUCTOR CASINGYM ® No Bata Dia Castq DM: CaD60L [3INJECTION &ftffN1jk" ❑ HANO AUGER GROAT SEAL DEPTH N TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER _ ❑ OTHER: - - - - - - GROUT SEAL PUMPED? ❑ YK No (rte FMW DOW k 30 Fq WELL/ SON. BORING Os — ---- �GROUTSPECIFICATIONS �, (,( S-f T C +U 'a i f4 (k) Pf/1COwn -- — Neat Cement - - – - - -- © DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THATAPPLYT if WELLS TO BE DESTROYED _ ❑ OVERBORE DIA)ETER of Mdm Io deo of fest WELL IDs ❑ PRESSURE GROUT To doo of feet below surface GROUT SPECIFICATIONS _ ❑ EXPL6SMVES From 10 (Bet below surface TREMtE TYPE TO BE USED AUGERS HOSE PIPE MUSHROOM CAP 3 teat below surface or feet balm surface K >3 feel COMMENTS : 3 borfts : 1 to 5 FT and 2 to 15 FT Grourxlwater sample wttl be collected In the 2 - 15 FT bork>Ds . 1 hereby cord y that 1 am euthorizod to complete this application and that the work will be done In accordance with saassappeassIJosqu n County Ordlaa Codas and Standards, and a4 o0wrapplicable .C411fornia`law� n. r Signed rnte/ComparSS(� tfl7�' �lS:?[k) L�Cllr(� tllv►��N " ' Print Name Date 11WIAN U DEPARTMENT USE ONLY Application Accepted By: A JrL00 Dale issued: 1 Grout Inspection ByMates : — DesinJction Inspection By/Dates: F cilli lSito Information { �, ' M\ ) ' , ►� FA Nems N'` .s. ob, ,pt` ll ' &z) r FA Address ' Z� Vj . FAX Q z S (tel ) � FA PE O WP IiavMwud By work Plan Dale 1 Z Z /04 G 57 ❑ Cb7 AuYa U&*n fur OYw b W port ❑ Wo%W& Come ❑ WwWs Cane Weller ❑ EMOKW t Pwml ❑ Acom Aww wt ❑ Lead Apocy Approval ❑ MFR COMM ENTSICONDmoNsc IV 0 im4 :04t (hUewS� JgtM 4S hP9sbi �+ y R1A) � ,Ge �(. r4o d Tl e. iqf� 1'�� '2_4. olr N INP TYPE PE Sd I EE INFO JAMT RF_AIIITTED CHECKS I RECV'D BY DATE WELL PERMITS INVOICENI Pemlit Z o 3 13$ 162 x 3 zl 9 � � W 1868 E . Hazefton Avenue I Stockton , Califom (a 952051 T 209 468-34201 F 209 464-0138 www.sIcehd .Gom EHD 2"1 0"M7 �AL)r (z ,� bq o