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SAN JOAQUIN 8 Environmental Health Department <br />S. American Street APN 147-292-090, <br />Phone N/A Property Owner* Christian & Maria Zamorano, et al <br />Address 820 S. American Street City/State/Zip Stockton <br />716 0 5 0 Phone (916) 852-9118 C-57 Contractor Geocon Consultants, Inc License# <br />Phone N/A Consultant/Sub-Contractor N/A License# <br />Address N/A City/State/Zip N/A <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 10 ft. 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 3 5 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS n/a TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER <br />OTHER: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs B6 and B7 GROUT SPECIFICATIONS Type 1 Portland cement <br />-0,4r-vv <br />Application Accepted By: <br />Grout Inspection By/Dates: /1/0.4 <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: (<9/Z,-) <br />7/5/ <br />- C Li1H T <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 />609 E. Worth Street (820 S. American Street) <br />Address 3160 Gold Valley Drive, Suite 800 city/state/zip Rancho Cordova, CA <br />Job Address <br />Cross Street <br />City/State/Zip Stockton, CA 95206 Phone N/A <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />ID MONITORING El <br />I=1 EXTRACTION (Vapor/Water) 0 <br />0 SOIL VAPOR PROBE 0 <br />51 SOIL BORING 2, IN <br />ci INJECTION (Air Spam. Ozone' , <br />0 OTHER cl <br />Signed r <br />t\); Print Name <br />I hereby c rtify that I am authorized to complete this application and that the work will be done in accordance with <br />n Joa in County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company c:?1)clf SL: k. or\ <br />kikt,d—A Date 6' <br />DEPAftJMENT USE ONLY <br />FA Name -,.. i . i / _ -, i t Ix:: LA,1 i..c , terla.L. te., FA Address M) s, Avvvery,.‘ ce, vt 5 r FA# 00 i._,..4 t,cy PR# o cti -s -tt_. <br />FA PE (?-40 0 WP Reviewed By L y Work Plan Date <br />) 1 Z-1 / f 1 <br />0 0-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement Ej 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 $152x <br />1868 E. Hazelton Avenue 1 Stockton, California 952051 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 <br />e_4):i ) S1-'3 CLX 3 LISAJ /VS,P0U L—X /.6 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS LI HOSE C] PIPE <br />LI OVER-BORE <br />fl PRESSURE GROUT <br />El EXPLOSIVES <br />['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 APPLY1 <br />COMMENTS: