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SAN JOAQUIN <br />- c.ouivrY--- <br />• <br />Environmental Health Department <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 17720 E. Harney Lane <br />Cross Street <br />City/StatelzipLodi, CA 95240 Phone (2119)887-38613 <br />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 License# C57485165 Phone (925)288-2381 <br />Address 4005 Port Chicago Hwy City/state/Zip Concord, CA 94520-1180 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Welis Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />91 MONITORING G-3 E ❑ HOLLOW STEM BORING DEPTH 190 f t ❑ BOLTED TRAFFIC BOX RI STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRWEN DIA. OF BOREHOLE 1011 O MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA 211 <br />❑ SOIL VAPOR PROBE 6d MUD ROTARY CASING THICKNESS RCH 90 TYPE OF CASING: ❑ STEEL Q PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (AirSoarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS IM HOSE IM PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? IE Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELUSOILBORINGI0s3i —L� GROUT SPECIFICATIONS Neat cement <br />water monitoring <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED ❑ OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From lo feet below surface <br />TREMIE TYPE TO BE USED [_-]AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or fast below surface 1>3 feet <br />COMMENTS:G-3E is located on the west side of North County Landfill. <br />hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joa uin C unty dIpance Codes and Standards, and all other applicable California laws. <br />SignedTitle/Company SAA,) JD"lni e.Wil "r r <br />Print Nm <br />ae (A*oa,- i Date % <br />DEPARTMENT USE ONLY <br />Application Accepted By: -W�a4 h CJ� v O 'T5 >., " c Date Issued: 11Z 21 /.8 <br />Grout Inspection By/Dates: _ <br />Destruction Inspection By/Dates: <br />0-11if.dAlfn I.M.—fl— <br />FA Name <br />FA Address <br />FAY <br />PRY <br />FA PE <br />WP Reviewed By <br />Work Pian Date <br />EIC -57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTSICONDITIONS: <br />WP TYPE <br />I <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECKS RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />/USPE <br />7-// 7/ <br />13 f <br />$152 X / <br />f SZ 5 <br />D t o <br />' l /�� <br />WQ �J% U y <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209468-34201 F 209464-0138 1 www.sjcehd.com <br />EHD 29-0108-0147 Sae Mitigation Wel Permit AppkWon <br />