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Pour" SAN J O A Q U I N Environmental Health Department <br /> v.�P � COUNTY-- <br /> air greatness grows here <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION NOV 0 9 2017 <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> ENVIRONMENT HEALTF[ <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 2222 & 2244 S.Airport Way City/State/Zip Stockton, CA, 95202 Phone <br /> Cross Street E 9th Street APN 137-300-11 <br /> Property Owner* City of Stockton Phone 209-937-8309 <br /> Address 425 N EI Dorado Street City/State/Zip Stockton, CA, 95202 <br /> C-57 Contractor V&W Drilling, Inc. License# C57-720904 Phone 209-469-7700 <br /> Address 3806 Duck Creek Drive City/State/Zip Stockton, CA 95215 <br /> Consultant/Sub-Contractor Condor Earth License# John LaneG 6795 Phone 209-234-0518 _ <br /> Address 188 Frank West Circle, Suite I City/State/Zip, St ckton, CA, 95206 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/W4ReqA AgtQetnents or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIF //❑ MONITORING ❑ HOLLOW STEM BORING DEPTH —5 feTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA OF BOREHOLE 2.2LTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA19 SOIL VAPOR PRDBE 4 ❑ MUD ROTARY CASING TH'CKNESS CASING: ❑STEEL PVC ❑ OTHER <br /> ❑ SOILBORING �PUSH POINT(GP CPT) CONDUCTOR CASING' Da` Casing D'a: CasingDepth <br /> ❑ INJECTION(AkSoarae.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH � IE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PiPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yote� aximum Freefall Depth is 30 FI) <br /> WELL/SOIL BORING IDs _ GROUT SPECIFICATIONS <br /> SV -L - <br /> DESTRUCTION WORK TO BE PERFORMED: ESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED �I ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs SVP-j tc -SV(-)—Lt El PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet be ow surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑ IPE ❑MUSHROOM CAP El feet below_ surface or feet below surface f>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 /> Sa=Jo^aquin County Ordinance Codes and Standards,and all other applicable C lifomi{a laws. <br /> Signed_ ` lIt' -� Title/Company �� �9 L (Md0V <br /> Print Name_ .J0 "� L6�e Date !ZV2� 0l <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information <br /> FA Name FA Address FAO PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑G57 ❑G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Corm Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE sC FEE INFO AMT REMrTTED CHECK#I RECV-D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 Site Mitigabon Well Permit Appi,cabon <br />