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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <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 310 W. Fremont St (Formerly 424 Van Buren St) City/State/Zip Stockton, CA 95203 Phone <br />Cross Street N. Van Buren Street APN 137-410-020 (City of Stockton ROW) <br />Property Owner* The City of Stockton <br /> <br />Phone 209-937-7569 <br />Address 425 N. El Dorado Street City/State/Zip Stockton CA 95202 <br /> <br />C-57 Contractor Woodward Drilling Co., Inc. License# C57-710079 Phone 707-374-4300 <br /> <br />Address 550 River Road <br /> <br />City/State/Zip <br />License# <br />Rio Vista CA 94571 <br /> <br />Consultant/Sub-Contractor <br /> <br />Phone <br /> <br />Address <br /> <br />City/State/Zip <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBOR1NG NUMBER <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE El <br />ID SOIL BORING 0 <br />ID INJECTION (Air some. Ozone) <br />ID OTHER <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 0 BOLTED TRAFFIC BOX ID STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC U OTHER <br /> <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br /> <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 3 <br />WELL IDs SV-1, SV-2 & SV-3 <br />GROUT SPECIFICATIONS Neat Cement <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE r] PIPE <br />0 OVER-BORE <br />I=1 PRESSURE GROUT <br />EXPLOSIVES <br />El MUSHROOM CAP <br />DIAMETER of 3.25 inches to depth of 5 feet <br />To depth of feet below surface <br />From to feet below surface <br />El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />Signed <br />I hereby certify that I am authorized t <br />San Joaquin County <br />./t <br />complete this application and that the work will be done in accordance with <br />mance Codes and Standards, and all other applicable California laws. <br />Title/Company Woodward Drilling Co., Inc. <br />Print Name Wayne Woodward Date 2/28/2019 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />447 <br />DE TMENT USE ONLY <br />Date Issued: 3//i <br /> <br />t-tly / 1 <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name FA Address 310 v1/4) 4 cr-tfeA0 4— ,q- FA# 0 02.5(3 ) PR# <br />FA PE )_1I,,() WP Reviewed By L v)/ Work Plan Date -? /24 /1 C7 <br />elT57 0 C-57 Authorization for Other to Sign Permit R1Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement Ilafe'ad Agency Approval E4R <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit vw 2_ -3 1 3 $152x 3 t LtSi, -311 L 1( 1 1 6 /Lc) l , -) e 003 cl 1 /4( 0 8 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application <br />251 o ‘crs 4 (C" 3 '51°' 631"; L f)( Vcit,c1 .st,0 0 8 'z-itc