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40.46 <br />s or Encroachment Permits CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/wells Require Access Agreem <br />WELU SOIL BORING IDs <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 55_75 ft El BOLTED T FIC BOX 0 STOVE PIPE <br />DIA, OF BOREHOLE 2 in El MULTIP CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF SING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Bodng • Casing ow: Casing Depth <br />GROUT SEAL DEPTH 75 ft, max TRE E TYPE TO BE USED: 0 AUGERS 1:1 HOSE M PIPE <br />GROUT SEAL PUMPED? 0 Yes CI No ( e: Maximum Freefall Depth Is 30 Fl) <br />GROUT SPECIFICATIONS neat c ent grout <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS: <br />P OVER ORE <br />PR SURE GROUT <br />E LOSIVES <br />USH ROOM CAP <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />3 feet below surface or feet below surface if >3 feet <br />D ES TR UC ON METHOD: (CHECK ALL THAT APPLY1 <br />Signed <br />Pal 162_,/ Print Name <br />I hereby certify that I am authorized to complete Is application and that the work will be done In accordance with <br />Sac Joaquipounty Ordinance Cod and Standards, and all other applicable California laws. <br />Tille/Company ft& Ai/• <br />Date ci ta, / .7 <br />TYPE OF WELL/BORING <br />0MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />IS]SOIL BORING <br />INJECTION (Air Soato Ozoridn <br />OTHER <br />NUMBER INSTALLATION TYPE <br /> CI HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> CI MUD ROTARY <br />3 IS] PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />CI OTHER: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.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 610 N. Hunter Street city/state/zip Stockton, CA 95202 <br />Cross street Oak Street <br />Property owner* Ray Farmer Enterprises Inc. <br />Address 2606 Sheridan Way <br />APN 139-060-33 <br />City/State/Zip Stockton, CA 95207 <br />Phone <br />Phone <br />C-57 Contractor Gregg Drilling & Testing <br /> <br />License# 485165 Phone 925-313-5800 <br /> <br />Address 950 Howe Road city/state/zip Martinez, CA 9453 <br />Consultant/Sub-Contractor ATC Group Services LLC License# Phone 209-579-2221 <br />Address 1117 Lone Palm Avenue, Suite 201B city/state/zip Modesto, C 5351 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name <br />LP <br />FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Parrott 0 Worker's Comp 0 Workers Comp Waiver ID Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK* RECV'D BY DATE SERVICE REQUESTS INVOICE# <br />Permit $139 x <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application