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) <br />\ ,— <br />ureorness grows here. <br />2;1,1 <br />SANJOAQUIN <br />--COUNTY <br />Environmental Health D ent <br />" 2 5 201a <br />SITE MITIGATION WELL & BORING PERMIT APPLICAiN L NA-ALV40,. <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 />Job Address 540 North Hunter Street city/State/Zip Stockton. California Phone (209) 467-1006 <br />Cross Street East Oak Street APN 139-060-230 <br /> <br />Property Owner Juen Lee <br /> <br />Phone (209) 467-1006 <br /> <br />Address 11699 Birchville Road <br />C-57 Contractor PENECORE DRILLING. INC. License# 906899 Phone (530)661-3600 <br /> <br />Address 220 N. EAST STREET City/State/Zip WOODLAND, CA 95776 <br /> <br />Consultant/Sub-Contractor AGE License# 680227 <br /> <br />Phone (209) 467-1006 <br /> <br />Address 837 SHAW ROAD City/State/Zip STOCKTON CA 95215 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BonngsANelis Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING <br />EXTRACTION PiaocrAVates, <br />0 SOIL VAPOR PROBE <br />HOLLOW STEM <br />O HAMMERDRIVEN <br />MUD ROTARY <br />BORING DEPTH 25 0 BOLTED TRAFFIC BOX 0 STOVE RIPE <br />DIA. OF BOREHOLE 1.25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING CIA <br />CASING THICKNESS TYPE OF CASING 0 STEEL 12 PVC 0 OTHER <br />2 CONDJCTOR CASING 0 Yes El Nn Borng Oa: Casmg Da' Cas.ing Depth: In SOIL BORING PUSH POINT (GP. CPT) <br />24.5' TREME TYRE TO SE USED 0 AUGERS 0 HOSE 13D PIPE INJECTION 0 HAND AUGER GROUT SEAL DEPTH <br />0 OTHER 0 OTHER GROUT SEAL PUMPED') 0 Yes (g) No (Note: Macmum Freetall ceomis3ort) <br />WELL SOIL BORING IDs & 8-9 GROUT SPECIFICATIONS PORTLAND TYPE II <br />City/State/Zip Nevada City, California <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 APPLY1 <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 (eel below surface or feet below surface if >3 feet <br />COMMENTS: " See work plan" <br />I h'ereby 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 taws. <br />Signed <br /> <br />Title/Company STAFF GEOLOGIST / AGE <br /> <br />Date <br /> <br />Print Name Rene M. Toth <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By• <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facuityibite <br />FA Narne <br />information <br />1- c C 612e14/4 4 -4' -0- FA Address I '-.4,,2 (J , 1-1,....../p<,,- cl---- FA# ( Pi. ,1 c ,Trt <br />FA PE WP Reviewed By Work Plan Date ,, j, <br />0 C-57 CI'C-S7 Autenzaken tor Other to Sgn Permit 9 Worfer's Como 0 Woncees Como War:er 0 Enmeshment Perm! 0 Access Agreement 0 Lead Agency Aroroval <br />COMMENTS/CONDITIONS: <br />WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT* INVOICE* <br />Permit 5152x 4 -.-' -' i - -_x (:, ' v- C 003.k-1R) _ <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 09-01-17 S.te141,tgatcn VVe.I Perm! App!,catJort <br />Date Issued. <br />