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DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS El HOSE CI PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) D OVER-BORE DIAMETER of inches to depth of feet l PRESSURE GROUT To depth of feet below surface 0 EXPLOSIVES From to feet below surface MUSHROOM CAP 0 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 J uln Co Ordinance Codes and Standards, and all other applicable California laws. kit4t.121:, ' Title/Company t 1/ sdi wiw Signed Print Name 14„/a/c62,-Ik-- Date Environmental Health MED Cr) 2 1 2017 ENVIRONMENTAL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICATION PERMIT/SERV^ 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 610 N. Hunter Street City/State/Zip Stockton, CA 95202 Phone Cross street Oak Street APN 139-060-33 Property Owner* Ray Farmer Enterprises Inc. Address 2606 Sheridan Way City/State/Zip Stockton, Ca 95207 C-57 Contractor Gregg Drilling & Testing Licensed/ 485165 Phone 925-313-5800 Address 950 Howe Road. Consultant/Sub-Contractor ATC Group Services LLC City/State/Zip Martinez, CA 94533 Licensett Phone 209-579-2221 Address 1117 Lone Palm Avenue, Suite 201B City/State/Zip Modesto, CA 95351 PERFORMED: *Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits INSTALLATION TYPE CONSTRUCTION SPESIFICATJONS HOLLOW STEM BORING DEPTH 55-75 rt. El BOLTED TRAFFIC BOX 0 STOVE PIPE HAMMER/DRIVEN DIA. OF BOREHOLE 2 in. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dla: Casing Depth: HAND AUGER GROUT SEAL DEPTH 75 ft. max TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE a g PIPE GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maxlmum Freofall Depth Is 30 Ft) GROUT SPECIFICATIONS neat cement grout D PARTMENT USE ONLY lo /*'1/-1 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: 'PAA Date Issued: - FA Name -it, , 6 1/4n1 A T—"I`•<— FA Address . 0 0 0 0 v x--,./ St FA# i!... (.. t :,•1 •1 PR# FA PE D-9 lif0 WP Reviewed By Work Plan Date 0 C-57 E(C---57 Authorization for Other to Sign Permit Workers Comp 0 Worker's Comp Waiver 0 Encroachment Permit 1:1 Access Agreement 'Lead Agency Approval IIPMFR COMMENTS/CONDITIONS: 11A 5 e.e.(ovit rx•8--tv.v-> c-.V1 40 So . I 64 c .•'^') i-vvaltin,, 7 1.1".-A"V‘. '')".. 1 L. x: .-- li A --t\r' .< '‘r•Ji:: r v ei4.bc4 fulA o-fel-1 .1 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit _1: v '''', l'.., $152x \ ... '\, \- - ?G. , c, l i,s -.i.. 1-.X w Li, 111 V.1 r 00 3-13 -Tr 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com END 29-01 08-01-17 Site Mitigation Well Permit Application C )910 57-3 1, 3 "k5v olSc bk,'1 cl I Se-c 01 (0=P-3L-'` SANJOAQUIN -COUNTY-- G I Ca t S S (.7 f V.' 11 (.• Phone CONSTRUCTION WORK TO BE TYPE OF WELL/BORING NUMBER 1:1 MONITORING El EXTRACTION (Vapor/Water) 0 El SOIL VAPOR PROBE SOIL BORING 3 INJECTION (Ait Soomo. Ozone) 0 OTHER 0 OTHER: WELL/ SOIL BORING IDs HP-7, HP-8, HP-9