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t <br />f <br />SANsJOAQUIN <br />C O U N T Y---- <br />�cr1=<a Crentness ornws here. <br />V 04— <br />Environmental Health%GfiWD <br />DEC z 9 2011 <br />ENVI ONMfNT <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIO4j"" # NTAL fEALTM <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 pennit 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 17720 E. Harney Lane CityiState/zKodi, CA 95240 Phone (209)887-3868 <br />Cross Street APN 065-120-04 <br />Property Owner* San Joaquin County PWD -Solid Waste Phone (209)468-3066 <br />Address 1810 E. Hazelton Avenue City/State/Zip Stockton, CA 95205 <br />C-57Contractor Gregg Drilling License# 485165 Phone (925)313-5800 <br />Address 950 Howe Road City/State/zip Martinez, CA 94553-3444 <br />Consultant/Sub-Contractor CB & I <br />Address 4005 Port Chicago Hwy <br />License# C57485165 Phone 422,a)288-2181 <br />City/state/zip Concord, CA 94520-1180 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ID MONITORING G -3E ❑ HOLLOW STEM BORING DEPTH 190 ft ❑ BOLTED TRAFFIC BOX ® STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE loll ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA 2 rr <br />❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS -,C14 90 TYPE OF CASING: ❑ STEEL Q PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (AirSparge. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS Id HOSE ID PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs —G3 --E GROUT SPECIFICATIONS Neat cement <br />water monitoring <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />COMMENT0:G-3E is located on the west side of North County Landfill. <br />r ner <br />Signed <br />and <br />tndards, and all otter applicable GaNfomia laws. <br />Title/Company Sttj jDCQ,tJI AJ r <br />Print Name 'rlt�'.r /Vi , 6 A'/.}'x} az-i Date L Z 21 % <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facillty/Site Infermatien <br />Date Issued: <br />FA Name <br />FA Address <br />FA# <br />PR# <br />FA PE <br />WP Reviewed By <br />Work Plan Date <br />❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />PE <br />Sc <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />$152 x <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29-0108-01-17 <br />Site Mitigation Well Permit Application <br />