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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N; < <br /> •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> q . '�• Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjcehd.com <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 /> 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 nrjllinn_ Inc_ License# C57-720904 Phone 209-469-7700 <br /> Address 3806 Duck Creek Drive City/State/Zip Stockton C:A A5215 <br /> Consultant/Sub-Contractor Condor Earth License# John Lane, PG 679.5 Phone 209-234-0,518 <br /> Address 188 Frank West Circle, Suite I City/State/Zip�Stacktan, CA 95206 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> W MONITORING 4® HOLLOW STEM BORING DEPTH 4n_ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE R j r1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes W No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs MW-1 though MW-4 GROUT SPECIFICATIONS <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 feet below surface if>3 feet <br /> COMMENTS: <br /> Soil Vapor Probes will be bored to a depth of 5'and the monitoring wells to 40'. SVP will have a borehole diameter of 2.25"and <br /> the holes will be filled in at the end of the day. <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 appliic7able Calif rnia laws. <br /> Signed Title/Company ( <br /> Print Name Date LU 3t <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Permit $139 x = <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />