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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT MAY 1 20,T <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 p."u/Vit/P.- Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.conYERitfi 10 'Yik Ng, <br />,06-Rvir, <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION -Es <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 />City/State/Zip Stockton, Ca <br />Phone 801 Diamond St. Job Address <br />Cross Street E. Worth St. APN 155-300-03 <br /> <br />Property Owner* BNSF Railway <br /> <br />Phone 909-386-4081 <br />Address 740 East Carnegie Drive City/State/Zip San Bernadino, Ca <br />C-57 Contractor Cascade Drilling, LP License# 938110 Phone 925-849-6970 <br /> <br />Address 1641 Challenoe Dr. City/State/Zip Concord, CA <br /> <br />Consultant/Sub-Contractor Kennedy/Jenks Cons. Inc. License# Phone 415-243-2150 <br />Address 303 2nd St. Ste 300 South City/State/Zip San Francisco CA 94107 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />El MONITORING <br />EXTRACTION (Vapor/Water) 0 <br />SOIL VAPOR PROBE <br />X BOIL BORING _ 5 x <br />INJECTION (Air Spam Ozone) <br />OTHER <br />WELU SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: _ <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 50 <br />DIA. OF BOREHOLE 2-1/4 <br />CASING THICKNESS n/a <br />CONDUCTOR CASING El Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? X Yes 0 No <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE X I PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> GROUT SPECIFICATIONS Neat Cement <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />I=J OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface WELL IDs <br />GROUT SPECIFICATIONS <br /> <br />O EXPLOSIVES From to feet below surface <br />11 MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet TREMIE TYPE TO BE USED El AUGERS El HOSE El PIPE <br />COMMENTS: <br />Signed <br />Print Name <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />S, /J oaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Title/Company <br />"I( 1z,ve /4cLe. 0,( Date <br />Application Accepted By: <br /> <br />USE ONLY <br />IS —11131 <br /> <br />Date Issued: <br /> <br />Grout Inspection By/Dates: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name / ; WS '17 4,41 FA Address (f O/ Dramba s j. FA# 00 ?..)r. PR# L.).-. 77 / ,(--7/1/7 <br />FA PE /7 zi.., sr) W7eviewed By Work Plan Date ,/3/ <br />fitlit <br />arC-57 0 C-57 Authorization for Other to Sign Permit fr Workers Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement Q lead Agency Approval FR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE , SERVICE REQUEST# INVOICE# <br />Permit Z):7c, - .'1,,, $139x ; / I/ i 7 i')" ' ri."--- 61/7-4-7 CV 7 74 .7/ <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application