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SAN JOAQUIN Environmental r,-lealth Department <br />: <br />COUNTY <br />inras--t"' <br /> <br />Gre.otness 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 />Job Address 540 North Hunter Street City/State/zip Stockton, California Phone (209) 467-1006 <br />Cross Street East Oak Street APN 139-060-280 <br />Property Owner* Juen Lee <br /> <br />Phone (209) 467-1006 <br />Address 11699 Birchville Road City/State/Zip Nevada City, California <br /> <br />C-57 Contractor PENECORE License# 906899 Phone (530) 661-3600 <br />Address 220 N. EAST STREET City/State/Zip WOODLAND, CA 95776 <br />Consultant/Sub-Contractor AGE License# 680227 Phone (209) 467-1006 <br />Address 837 SHAW ROAD 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 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM BORING DEPTH 25' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 1.25 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE 1:1 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 10 PVC ID OTHER <br />Ea SOIL BORING 7 N PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes El No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION (Air Sparie Ozonel ID HAND AUGER GROUT SEAL DEPTH 24.5' TREMIE TYPE TO BE USED: El AUGERS 0 HOSE El PIPE <br />OTHER 1:1 OTHER: GROUT SEAL PUMPED? 0 Yes El No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs B4.'"igp.' 13-1 R-4 R-5 B-6, A R.7 GROUT SPECIFICATIONS PORTLAND TYPE ll <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 />fl OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP <br /> <br />0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: ** See work plan ** <br />I hereby cerytt that I am authorized to complete this application and that the work will be done in accordance with <br />S. r" o ty Ordinance Codes and Standards, and all other applicable California laws. <br />Repe M. Toth <br />Signed Title/Company STAFF GEOLOGIST /AGE <br />Print Name Date 6/13/18 <br /> <br />DEPARTMENT USE ONLY <br /> <br />(,/ 5 At <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />I sf <br /> <br />FA Name I-LL FA Address 'yLi^„.7 , j. , 1 ,. _A i . FA# , 1, t: ;) PR# -, <br />FA FA PE ,-2-41 Ct; WP Reviewed By .3,- Work Plan Date (..4, / / 3 1 <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Workers Comp Waiver 0 Encroachment Permit I71 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit .25Ie 5" 717. $152x , ... . <br />,1.7)-hr <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />st.3 J- ‘C'/(1