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SAN JOAQUIN 8 <br />--COUNTY <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 />Job Address 824 S. American Street (820 S. American Street) city/state/zip Stockton, CA 95206 Phone N/A <br />Cross street Worth Street APN 147-292. 11Z), <br /> <br />Property owner* Christian & Maria Zamorano, et al Phone N/A <br /> <br />Address 820 S. American Street City/State/Zip Stockton <br />C-57 Contractor Geocon Consultants, Inc License# 716050 Phone (916) 852-9118 <br /> <br />Address 3160 Gold Valley Drive, Suite 800 <br /> <br />City/State/Zip Rancho Cordova, CA <br /> <br />Consultant/Sub-Contractor <br />Address N/A <br />N/A License# N/A Phone N/A <br /> <br />City/State/Zip N/A <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />0 MONITORING <br />EXTRACTION Napor/Water) <br />El SOIL VAPOR PROBE <br />ix SOIL BORING <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D HOLLOW STEM BORING DEPTH 10 ft. 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE 3 5 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 MUD ROTARY CASING THICKNESS n/a TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />5 21 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION (Air Spare Ozonel p HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER B1 - B5 D OTHER: GROUT SEAL PUMPED? 0 Yes 2 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS Type 1 Portland cement <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />D OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br /> <br />GROUT SPECIFICATIONS LI EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED LI AUGERS D HOSE El PIPE ID MUSHROOM CAP D 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />rtify that I am authorized to complete this application and that the work will be done in accordance with <br />n Joa n County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Companyc:?( 5L f /6- (.0( or, . <br />thereby c <br />' <br />Signed r ,' <br />14,-, Print Name Date <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />DEPARTMENT USE ONLY <br />L2' C/Arvi I kL,L • <br /> <br />Date Issued: <br />7/5/ <br /> <br />FA Name , t ci to, Co ,.A „4.4,4 1,,, .. FA Address gle C A•yvx,v-i Li_ ,, 511— FM 0 cri,i g 0.1 PR# <br /> <br />FA PE ,)-1,(a0 WP Reviewed By L- )( Work Plan Date C. f ,1_,.7 I i 1 <br />n 0-57 D 0-57 Authorization for Other to Sign Permit El Worker's Comp 0 Worker's Comp Waiver p Encroachment Permit 0 Access Agreement 0Lead 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 ;&effe 0 3nk -1 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application