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SAN JOAQUIN fat%) Environmental Health Department <br />- CCDUI\ it \;" <br />ureotness vows 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 fcr 3 permit to construct and/or install the work descnbed <br />Tnrs application is made in compliance witn San Joaquin County Development Title. Chapter 9-1115.3 and the San Joaquin County Well Standards. <br />Job Address 705 Carlton Avenue city/state/zip Stockton/CA/95203 Phone <br />Cross Street Park Street ApN 133-210-03 <br />Property Owner Vertiv Group Corporation (Attn: Jacob Watson) Phone 440-288-1122 <br />Address 1050 Dearborn Drive City/State/Zip Columbus/OK43085 <br />C-67 Contractor Environmental Control Associates (ECA) License/ 695970 <br />Address 3011 Twin Palms Drive city/state/zip Aptos/CA/95003 <br />Consultant/Sub-Contractor EFI Global Licensee 885902 Phone <br />Address 433 Airport Blvd., Ste 303 City/State/Zip Burlinaame/CA/94010 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note DIfsite Borings:Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />mcirirroroNG 0 HOLLOW STEM BORING 7,EPTH 10 feet bgs 0 BOLTED TRAFFIC BOX 0 arm PIPE <br />0 ExTRACTiON ivapc Wok., 0 HAMMER/DRIVEN DIA OF BOREHOLE 2251achas 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING GM <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS N/A TYPE OF CASING. 0 STEEL 0 PVC 0 OTHER <br />CI SOL BORING ...8" is, 0 PUSH POINT (GPI CPT) CONDUCTOR CASING 0 IS END Bala; Da Casey Dia Care DNA <br />INJECTION IA/ $.1M0 , ,:,' ‘,. 0 HAND AUGER GROUT SEAL DEPTH TREMtE TYPE TO BE USED. 0 AUGERS 0 HOSE NI PIPE <br />OTHER lia OTHER. Direct Push GROUT SEAL PUMPED'', C Yos CV No ‘I.44e Mammal Freetan Dem 830Fq <br />Weil SOiLBOPiteG iDs ,510/(Bst B3, 614, 85. 86, 87, 88 GROUT SPECIFICATIONS Cement grout from terminal depth to within 6 inches of surface in <br />each boring. Resurface with concrete. <br />Phone _916-417-8179 <br />415-857-8517 <br />DESTRUCTION WORK TO BE PERFORMED: <br />is WELLS TO BE DESTROYED <br />WELL iDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br />COMMENTS: <br />AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: iCHECK ALL THAT APPLY, <br />0 OVER-BORE DIAMETER of ric•-•,es to dear. CI feet <br />PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />MUSHROOM CAP Ej 3 feet below sLnace or fee! below saface if >3 fee. <br />I hereby certify that I am authorized to complete this application and that the work will be dons in accordance with <br />San Joaquin County Ordinance Codas and Standards, and all other applicable California laws. <br />an Signed <br />Print Name TM Tyler ti -it S. r-inr ,,(3rri 0- 64-4 Spate 1 t y <br />Title/Comp/ President / ECA <br />Application Accepted By <br />Grout Inspection 13y,Cates <br />Destruction Inspection ByiDates <br />I <br />ONLY <br />Date Issued 1,--)/3)1 <br /> <br />< <br /> <br />L.,j L <br /> <br />itaCilityibite <br />A Nam.: <br />inrormati 11 <br />FA Address -"vs- J. Cz_ii t-0 rt. AMte, FAia 00 . 7 PR* <br />0943.1 , i <br />FA PE ,L.)-1,j-L WP ReNtewed By LX Work Pilo Date cl htliv —, <br />0 C-57 ar:-Autt =ration to; Otner to sign Permit CV‘ers Comp 0 Worker's Dom wave( 0 Encroachment Penni 0 ACOOSIS kiwis* 0 Leal AgencY *mull v ', <br />COMMENTS/CONDMONS: <br />CHECK*1-RECVD BY DATE WELL PERMIT* INVOICE* WP TYPE PE SC FEE INFO ANT REMITTED <br />Permit ftitx, 30 $152x -3 4 4,ci. 9-744-s11.4 <br />A, L.)( '1i/ i aroo3fttvi <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29.01 Su Mitigation WM Ponnit Apoicsoon <br />146 90 i'c2-)r 3 4'1 8.3011 I 7 L x litclily s +too IA,