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City/State/Zip Stockton, CA 95202 <br /> APN 139-060-15 <br />Job Address 619 N. San Joaquin Street <br />Cross street Oak Street <br />SAN JOAQUIN COUNTY RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT MAR 0 <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />EiwiR <br />8 <br />201 N <br />0 <br />uE <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com PEWIT/sr - 'nEALTH <br />tROCES 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 />Phone <br />Property owner* Ray Farmer Enterprises Inc. Phone <br />Address 3810 Fourteen Mile Drive city/state/zip Stockton, CA 95202 <br />C-57 Contractor Gregg Drilling &Testing License# 485165 Phone 925-313-5800 <br />Address 950 Howe Road city/state/zip Martinez, CA 94553 <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, CA 95351 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLJBORING <br />El MONITORING <br />0 EXTRACTION (Vapor/Water) <br />0 SOIL VAPOR PROBE <br />ag SOIL BORING <br />El INJECTION (Air Spam. oxonat <br />0 OTHER <br />WELU SOIL BORING IDs <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 HOLLOW STEM BORING DEPTH 1 0-6() ft. CI BOLTED TRAFFIC BOX 0 STOVE PIPE <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE 2 in. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />El MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL PVC 0 OTHER <br />8 181 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dla: Casing Depth: <br /> 0 HAND AUGER GROUT SEAL DEPTH 60 ft. max TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 2 PIPE <br /> 0 OTHER: GROUT SEAL PUMPED? El Yes ID No (Note: Maximum Freefall Deplh Is 30 Ft) <br /> GROUT SPECIFICATIONS neat cement 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 />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />E OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />GI EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I a utherized to complete this application and that the work will be done In accordance with <br />, San Joaqul Cc)unty Ordinance Codes and Standards, and all other applicable California laws. <br />-1'0 '...---- Title/Company b ' t. ex )kg. ,(44-5 , <br />/ 7 <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 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 Permit 0 Worker's Comp 0 Worker's 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 DAT SERVICE REQUEST# INVOICE# <br />Permit 740,;( i lic- $139x ,...... / iti .7 <br />,-; <br />L_ i 1 <br />, r,........------ <br />' V2,t(7 ) 0 7'70 0 0 <br />--27Q 4. z.,3 . 7 <br /> <br />c"1 0-0 7 7 S — <br />EHD 29-01 10-26-2015 <br /> <br />Site Mitigation Well Permit Application <br />Signed <br />Print Name jZi/ I,J2--/4L4 Date