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SA KJ OAQ U I N Environmental Health Department COUNTY c��rFOF:>4' Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION 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. Job Address 7525 Liberty Rd City/State/Zip Galt, CA Phone Cross Street Dustin Rd APN 00702018 209-468-2630 Property Owner* San Joaquin County Phone Address 44 N. San Joaquin St. City/State/Zip C-57 Contractor Cascade Drilling License# 1058336 Phone 916-638-1169 Address 3000 Duluth St. City/State/zipWest Sacramento, CA 95691 Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITOR NG 2 ❑ HOLLOW STEM BORING DEPTH 1,700' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor,Water) ❑ HAMMENDRIVEN DIA.OF BOREHOLE IX MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE MUD ROTARY CASING THICKNESs2.5'SCh 80 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BOR NG ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth ❑ INJECTION(Air Soarae,ozone l ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? W Yes ❑No (Note.Maximum Freefall Depth is 30 Fl) WELL/SOIL BORING IDsonl�mq Well B GROUT SPECIFICATIONS See atta .h .d well construction detail diagrams- DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed um�4 Title/Company Cascade Drilling Print Name Jim Whitley Date12/11/20 DEPARTMENT USE ONLY c Application Accepted By: Date Issued: /Zv''ZA Grout Inspection By/Dates: Zv L Destruction Inspection By/Dates. Facility/Site Information C FA Name A C, 6 GI/✓ FA Address � S�s L,�¢ �� FAN �A 00 Z 629 9 PR# ��05Y6y 1 y FA PE ':Z`465 WP Reviewed By �4 r A *FpN,�Bc/&,— EIC-57 � Work Plan Date 2 /1 (/20� ❑C-57 ❑C-57 Authorization for Other to Sign Permit I]Worker's Comp ❑Worker's Camp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval /'J�MFR COMMENTS/CONDITIONS: WelkS rKuA4 !__ o„yid by D/V�j' Ir III�G 0►� e?<P1os VQs u5>< well does o,4 kmt+ Zok+r� WP TYPE PE SC FEE INFO AMT REMITTED C`H��ECK# RECV D BY DATE WELL PERMIT* INVOICE# Permit � 11 q0 3« $152x �p3o' .e�0 -- 5S7 rD•A • I/OZ`ZoZ^ L/1l 00 y 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHO 2"108-01-17 Site Mitigation Well Permit Application