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tr <br />SAN JOAUUIN Environmental Health 1447 <br />-COUNTY <br />Grrirtric,cc r7rows <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIC5NZWrisnoi, <br />For Wells and Borings Used for Contaminant Investigations and Remediation "ISI/C --s‘147:11 <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 />FEE? <br />'iv viPo 3 201'0 <br />Job Address 517 WEST FREMONT STREET <br />Cross Street NORTH LINCOLN STREET <br />Property Owner* DAVE GUARDINO, GUARDINO AND CRAWFORD <br />Address <br /> 517 WEST FREMONT STREET <br />C-57 Contractor GULF SHORE CONSTRUCTION SERVICES <br />Address PO BOX 1501 <br />Consultant/Sub-Contractor AGE <br />Address 837 SHAW ROAD <br />City/State/Zip STOCKTON, CA 95203 Phone (2 09) 467-1006 <br />APN 137-214-10 <br />Phone (209) 467-1006 <br />City/State/Zip STOCKTON, CA 95203 <br />(916) 939-4117 License# C57-964224 Phone <br />City/State/Zip SHINGLE SPRINGS, CA 95682 <br />(209) 467-1006 License# 680227 Phone <br />City/State/Zip STOCKTON, CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />1:1 MONITORING <br />EXTRACTION (Vapor/Water) <br />El SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spam. ozone) <br />OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />C1 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING I=1 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <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 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 18 <br />WELL IDs MW-1, -2, -4, -7, WV-1, -2, OW-1, -2, EW-1, OB-1, -2, IAS-1 10 -5: VP1 -2 <br />GROUT SPECIFICATIONS PORTLAND CEMENT TYPE II <br />TREMIE TYPE TO BE USED M AUGERS HOSE PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />IN OVER-BORE <br /> <br />DIAMETER of 8.25 inches to depth of 36 feet <br />PRESSURE GROUT To depth of feet below surface <br />fl EXPLOSIVES <br /> <br />From to feet below surface <br />MUSHROOM CAP <br /> i=13 feet below surface or feet below surface if >3 feet <br />COMMENTS: SEE WORK PLAN DATED 12 FEBRUARY 2018 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Sa p Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />1(A OtAAA-"-- Title/Company STAFF GEOLOGIST! AGE <br />Print Name ERIN ROTTACKER Date 12 FEBRUARY 2018 <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />CUL • <br /> <br />FA Name L14.0-iii.:Ve'C' "vrA (mr'''''11"-0 <br />Ca *-Skyvaph.A.-‘ <br />FA Address '.:- 1 Li TrAPA- 5k FA#l) 23 1.1-- e(4 PR# 09,10;g3 <br />FA PE / <br />0--CW .-N WP Reviewed By L -Y Work Plan Date 'Y ,---2, \ --,? A <br />CI C-57 C/C-57 Authorization for Other to Sign Permit El Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit ,),SWL. ; i.:). $152x <, 1, X )/41 i I Z 0 CO 11 <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjcehd.com <br />. Site Mitigation Well Permit Application EHD 29-01 08-01-17._ <br />;04 1:5 6-2. A 4'&c1. /, c f_00 -m cci <br />a5-03 <br />Signed