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SANJOAQUIN <br />COUNTY <br />reotness grows h <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 CITY RIGHT OF WAY - S SUTTER ST. <br />Cross Street W. 8TH ST. <br />Property Owner* CITY OF STOCKTON <br />Address 425 N EL DORADO ST <br />C-57 Contractor ALL WELL ABANDONMENT <br />Address 3369 FITZGERALD RD STE. B <br />Consultant/Sub-Contractor AGE <br />City/State/Zip STOCKTON, CA 95206 Phone <br />APN <br />Phone (209) 937-8444 <br />City/State/Zip STOCKTON, CA 95202 <br />(916) 363-9355 License# 848359 Phone <br />City/State/Zip RANCHO CORDOVA, CA 95742 <br />License# 680227 Phone (209) 467-1006 <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br /> <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 />El MONITORING El HOLLOW STEM BORING DEPTH 125' ID BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 8.25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CI SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />El SOIL BORING 2 El PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />ID INJECTION (Air Spume, Ozone( 0 HAND AUGER GROUT SEAL DEPTH 125' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE (8:1 PIPE <br />0 OTHER 0 OTHER: GROUT SEAL PUMPED? On Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs B-14, B-15 GROUT SPECIFICATIONS PORTLAND CEMENT TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED 0 OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED I=I AUGERS ID HOSE 0 PIPE 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: SEE WORK PLAN DATED 25 OCTOBER 2016; WATER TO BE DISPLACED THROUGH DIVERTER ATTACHED TO AUGERS, VACUUM <br />ON STANDBY TO USE AS NEEDED. <br />hereby certify that lam authorized to complete this application and that the work will be done in accordance with <br />Sri Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />/tkA A LCAC,iUA-^- <br />Print Name ERIN ROTTACKER <br /> <br />Date 09 AUGUST 2018 <br /> <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />-g /(,11, fr; <br /> <br />FA Name i\kt, 6, i I 1 ft FA Address Lk Vil 1 CI iNu,-i.Z) si FA# 00 2-'1 I i PR# 0 N7' 2.... <br />FA PE a914a 0 WP Reviewed By L. Work Plan Date ,-)1 :7, 1:,-- 1(•.!, <br />0 C-57 067 Authorization for Other to Sign Permit :Marker's Comp 0 Worker's Comp Waiver El/Encroachment Permit 0 Access Agreement 0 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 ).1 (:,'5 2,1 $152x 2., f co p-i-it,01 L X 4 L-S l;i ki--i t 6' iYlg til 1 -1 <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 <br />e ts--2-)( 2ut46,-1 111,01 ---rt <br />Signed Title/Company STAFF GEOLOGIST / AGE