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RECEIVED SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT tviAR 08 2017 <br />ENVIRON 1868 HazeIton Avenue, Stockton, CA 95205-6232 ra, „M ENTAL HEAL714 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.cog"nniT/SERWcEs' <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 Phone <br />Cross street Oak Street APN 139-060-33 <br /> <br />Property Owner* Ray Farmer Enterprises Inc. <br />Address 2606 Sheridan Way City/State/Zip Stockton, CA 95207 <br />Phone <br />C-57 Contractor Gregg Drilling 8c Testing <br /> <br />License', 485165 Phone 925-313-5800 <br /> <br />Address 950 Howe Road City/State/Zip Martinez, CA 94533 <br />Zglf-;) ei <br />Address 1117 Lone Palm Avenue, Suite 201B city/State/Zip Modesto, CA 95351 <br />Consultant/Sub-Contractor ATC Group Services LLC License# Phone 209-579-2221 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE <br />CI MONITORING 1:1 HOLLOW STEM <br />0 EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />0 SOIL VAPOR PROBE CI MUD ROTARY <br />IX1 SOIL BORING 6 [8] PUSH POINT (GP/ CPT) <br />El INJECTION (4 Seautt.Ozonol El HAND AUGER <br />CI OTHER El OTHER: <br />WELL/ SOIL BORING IDs <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 10-60 ft. CI BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 2 in. 0 MULTIPLE CASINGS 1:1 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC El OTHER <br /> <br />CONDUCTOR CASING CI Yes CI No Boring Dla: Casing Dla: Casing Depth: <br />GROUT SEAL DEPTH 60 ft. Max TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE M PIPE <br />GROUT SEAL PUMPED? CI Yes CI No (Note: Maxlmum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS neat cement grout <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED D AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />DOVER-BORE DIAMETER of inches to depth of feet <br />D PRESSURE GROUT To depth of feet below surface <br />EJ EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />gaq <br />rtify th, am nut <br />Sarytl inpou <br />Print Name 1/ <br />ed to complete this application and that the work will be done in accordance with <br />rdinance Codes and Standards and all other applicable California laws. <br />Title/Company <br />Date 74 <br />Signed <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />faciLitv/Site Information <br /> <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />D C-57 CI C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Workers Comp Waiver 0 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 REQUEST# INVOICE# <br />Permit Z40 C 313 $139 x 1 7 07 Z/7 rti---- 5/7))1/17 449 00-770)(3 <br />ouz. 3 (17 <br />EHD 29-01 10-26-2015 <br />44 66 7-6 q7 <br />Site Mitigation Well Permit Application