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SANI,JOAQUIN <br />— COUNTY <br />Environmental Health Department <br />Phone <br />Cross Street A I wkonj D6v <br />City/State/Zip I-ADA , (A c-15 2 (-1 <br />APN (j:/..- 060 - (f) <br />Job Address 112 Soç,Jk Chef ok-e e <br />Greatness grov,s here. <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 />48 Hours Advance Notice Required For All Inspections <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 />C-57 Contractor ErTobe_ rak,rk-5 <br />Address P.C, (oc15 , <br />consultant/Sub-Contractor L)G\1WC- — Kle,k A 5 5 ,c ,oke <br />Address ),-7)(5- -57n.CtuJ" 4 r" aVA. <br />City/State/Zip Py.);se, jO%13C)9 <br />License# lOI 2-2C4C4 Phone 53'D - 6 q3 -0 2 19 <br />City/State/Zip 0,0v1 le, (,4 559(0(0 <br />License# Phone 9 16 -3 -12- (93 41 <br />City/State/Zip \,,./.71 f Sac re.in r \It ), (A 156 9 / <br />Property Owner* G-e,OrDC C , Z. <br />Address 'Yl>tiS S . Tivica Aivem,e <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> o HOLLOW STEM <br />0, HAMMER/DRIVEN <br /> El MUD ROTARY <br /> 0 PUSH POINT (GPI CPT) <br />O HAND AUGER <br /> o OTHER: <br />BORING DEPTH '20 1 1 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA OF BOREHOLE ...3) • 11 . 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS — — TYPE OF CASING . 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth . <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes Ca No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS 4- Ct " -7 <br />TYPE OF WELL/BORING <br />1=] MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE SOIL BORING 14 <br />INJECTION ViAr Sparqe. ()zona( <br />El OTHER <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> <br />- 1 <br /> <br />WELL/SOIL BORING IDs FbI , 62_ I6 6 4 <br />DESTRUCTION WORK TO BE PERFORMED: <br />4 WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS El HOSE PIPE <br />0 OVER-BORE <br />El PRESSURE GROUT <br />El EXPLOSIVES <br />El MUSHROOM CAP <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />El 3 feet below surface or feet below surface if >3 feet <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed Title/Company E'r-\\ ‘> 6---e0103, •{- 0,(C - (<4...J.ek <br />Date <br />DEPARTMENT USE ONLY <br />Application Accepted By: JEFFREY WONG <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />3/31/2021 Date Issued: <br />FA Name GEORGE & LINDA WINGE TRUST FA Address 1721 S. CHEROKEE FA* FA0026453 PR# PR0546616 <br />FA PE 2950 WP Reviewed By JW Work Plan Date 3/26/2021 <br />0 C-57 qC-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Corny Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval gi MFR <br />COMMENTS/CONDITIONS: SUBMIT REPORT TO EHD PER SJC WELL STANDARDS 12.7.3. IF CONTAMINATION IS FOUND, <br />THE PROPER ENFORCEMENT AGENCY (I.E. RWQCB) MUST BE NOTIFIED. <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 2905 313 $152x 3 456 CC JW 3/26/2021 WP0041882 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sjcehd.com <br />EHD 29-01 08-01-17 Confirmation Number 122780292 SR0083485 Site Mitigation Well Remit Application <br />Print Name <br />I. Co19,re) <br />Phone L1O5- '11 (1 - 11 30 <br />COMMENTS: