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SANJOAQUIN <br />-COUNTY - <br />Gregtness grows her ,- <br />Environmental Health Department <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 />CITY OF STOCKTON RIGHT-OF-WAY <br />Job Address 517 WEST FREMONT STREET City/State/Zip STOCKTON, CA 95203 Phone (209) 467-1006 <br />Cross Street WEST FREMONT ST / NORTH LINCOLN ST APN <br />Property Owner* CITY OF STOCKTON <br />Address 425 N EL DORADO ST City/State/Zip STOCKTON, CA 95202 <br /> <br />C-57 Contractor GULF SHORE CONSTRUCTION SERVICES License# C57-964224 Phone (916) 939-4117 <br />Phone <br />Address PO BOX 1501 <br />City/State/Zip SHINGLE SPRINGS, CA 95682 <br />Consultant/Sub-Contractor AGE License# 680227 Phone (209) 467-1006 <br />Address 837 SHAW ROAD <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 NUMBER <br />0 MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE 0 <br />El SOIL BORING 0 <br />INJECTION (Air Sparqe, Ozonel 0 <br />OTHER 0 <br />WELL/ 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 <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? U Yes 0 No <br />GROUT SPECIFICATIONS <br />ID BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: U STEEL 0 PVC 0 OTHER <br /> <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 /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 2 <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of 8.25 inches to depth of 26 feet <br />ID PRESSURE GROUT To depth of feet below surface <br />fl EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 3 feet below surface or feet below surface if >3 feet <br />WELL IDs MW-5 AND MW-6 <br /> <br />GROUT SPECIFICATIONS PORTLAND CEMENT TYPE II <br /> <br />TREMIE TYPE TO BE USED is] AUGERS El HOSE j PIPE <br /> <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 />Sari Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />\-k..AAAA \Lit Gle.A.A.A--, Title/Company STAFF GEOLOGIST / AGE <br />Print Name ERIN ROTTACKER Date 12 FEBRUARY 2018 <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 />FA Name <br />(.: — --.. .1 .--0 41,,,,-e-L (Ark,. Awl <br />(..A-ev.S ilfttpt\tail <br />FA Address <;-- •*1 vj v.re , srf FA# 0 02..: i.,A - L. PR# c vc lick, 3 <br />FA PE <br />.,- <br />.-Y CIA, WP Reviewed By L. Y Work Plan Date 2- it l I ig <br />CI C-57 M C-57 Authodzation for Other to Sign Permit 0 Worker's Comp 0 Workers Comp Waiver 1Encroachment Permit 0 Access Agreement ID Lead Agency Approval EKFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit d.u'4... 5, t $152x ..)..., .5 -...:A k%bi.- i L -)C .--li <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application