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SAN JOAQUIN <br />COUNTY <br />Pec eft.° <br />Environmental HealtikSgOqryilent <br />4/1 .4734 <br />7447-&44 tii <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 730 Channel Street City/State/Zip Stockton, CA 95202 Phone 208-373-2803 <br />Cross Street E Weber Avenue ApN 139-270-100.000 <br /> <br />Property Owner Community Medical Centers, Inc. <br /> <br />Phone 209-373-2803 <br /> <br />Address 7210 Murray Drive City/State/Zip Stockton, CA 95210 <br />C-57 Contractor Environmental Control Associates. Inc. License# 695970 Phone 831-662-8178 <br /> <br />Address 3011 Twin Palms Drive <br /> <br />City/State/Zip Aptos, CA 95003 <br /> <br />Consultant/Sub-Contractor eScreen Logic LICeeSea N/A Phone 916-288-8170 <br /> <br />Address 11249 Gcld County Blvd Suite 165 City/State/Zip Gold River. CA 95670 <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 0 HOLLOW STEM BORING DEPTH 25-feet 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />El EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 2.5-inch El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />0 SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 13 PVC 0 OTHER <br />0 SOIL BORING 3 0 PUSH POINT (GP/ CPT) CONDLICTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />0 INJECTION (Air Spann, Om* 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS CI HOSE 0 PIPE <br />0 OTHER 0 OTHER: OPT GROUT SEAL PUMPED? 0 Yes El No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED N/A <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 />El PRESSURE GROUT To depth of feet below surface <br />['EXPLOSIVES From to feet below surface o MUSHROOM CAP 12 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />Signed <br />Print Name <br />I hereby certify that I am authorized to complete this application and that the work will be done In accordance with di/rati San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />R1,10, \ "AAA rro70 <br />Title/Company e5aern <br />Date I if/ (Jg <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: .1.- 1-`1 <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site information <br />t C -2 <br />FA Name :- "." 'A- 'k"-1 'PA' e-A.'.,-,-k <br />.:. . X....4_, C 4.,rA--Crs FA Address 13(2 C 41 it< 1 c t— FA# COL 01 0 PR# 0 yi k, ) <br />FA PE :)-Cict) WP Reviewed By <br />1.--- ::)(- Work Plan Date ) .1_ -k 1 5( <br />D C-57 P/657 Authorization for Other to Sign Permit iS4.orlier's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 24 <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK* RECV'D BY DATE WELL PERMIT* INVOICE# <br />Permit 25) k.,NS -,113 $152 x .3 --c '"i/C1,' VS-1 Leill (-- - )e. 0 Z.- VI P0 04•J 5rits73- <br />1868 E. Hazetton Avenue! Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 c.c.s-10,4 #(140,0 l i g/ or Mitigation PermApplication <br />2SW.5 152' k/ cro