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,op.0 N <br />SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Greatness grows her' <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 MCKINLEY PARK <br />Cross Street W. 8TH ST. & S. SAN JOAQUIN 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 167-060-010-000 <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 />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 />IKI MONITORING 1 Eg HOLLOW STEM BORING DEPTH 100' gi BOLTED TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 8.25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS SCHED 40 TYPE OF CASING: 0 STEEL IN PVC 0 OTHER <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air soars& ozone) 0 HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs MW-i1 <br />CONDUCTOR CASING 0 Yes LE No Boring Dia: 8" Casing Dia: 2" Casmg Depth 90' <br />GROUT SEAL DEPTH 83' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE IN PIPE <br />GROUT SEAL PUMPED? Ig:1 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS PORTLAND CEMENT 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 APPLY) <br />0 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 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 />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />, Sa Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed •,{AA \L„,t <br />Print Name ERIN ROTTACKER <br /> Date 09 AUGUST 2018 <br /> <br />DEPARTMENT USE ONLY <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 />tivizA-14 <br /> <br />FA Name i ,(1 k i i / D.v‘,1 ft-we've FA Address '220.-14 1 _ 1C. k '''..1 roat.0 S-I FA# 00-L4 7 ( PR# E)-gli 3 I. 6 2. <br />FA PE ?-91- 619 WP Reviewed By L — N<' / Work Plan Date t 0 1.1,s,-- ) I <br />0 C-57 IN/C.757 Authorization for Other to Sign Permit 'Worker's Comp 0 Workees Comp Waiver a(ncroachment Permit 0 Access Agreement 0 Lead Agency Approval r2KIFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit Q,CL C I '3 1) $152x 1 1 ( 5 2- -dlii A V Li 1— ') 47:311 S' 4J(1/4 0 <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 />Title/Company STAFF GEOLOGIST / AGE