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r <br />t • �rpU7N C� <br />y7kS Q N) Q Q Q Environmental Health Department <br />a'�' COUNTY <br />Greatness grows 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 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 City/State/Zipl.odi, CA 99940 Phone (909)887 -3868 - <br />Cross <br />868 - <br />Cross Street APN 065-120-04 <br />Property Owner* San Joaquin County PWD—Solid Waste <br />Address 1810 E. Hazelton Avenue <br />City/State/Zip Stockton, CA 95205 <br />C-57Contractor Gregg Drilling License# 486165 Phone (925)313-5800 <br />Address 950 Howe Road City/State/Zip Martinez, CA 94553-3433 <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 />Phone (209)468-3066 <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 />® MONITORING G%A ❑ HOLLOW STEM BORING DEPTH 179 ❑ BOLTED TRAFFIC BOX iI STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE loll ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA 211 <br />❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS SCH 80 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS IN HOSE ® PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 5d Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs G6A GROUT SPECIFICATIONS Neat cement <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 />Fummr-m'O' <br />G6A located on the west side of North County Landfill. <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Sa Jo n tunty Ordinance Codes and Standards, and all other applicable California laws. <br />Signed 1�� Title/Company San Joaquin County <br />Print Name —rltj (r. '6k#719 o f Date <br />DEPARTMENT USE ONLY <br />Application Accepted By: /� ; y �u��- ^— t Date Issued:%�Z 2-Ilt <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />r.,..rrrs.dalte 1.,c.. ­4r..., <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 ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />JAMT REMITTED1 CHECK# REC/VSD BY <br />DATE <br />PERMIT# <br />INVOICE# <br />Permit <br />Yy7( <br />,3f31$1521 <br />r <br />/5�. L6 <br />16 <br />nWELL <br />V1}f c� <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />EHD 29-0108-01-17 Site Mitigation Well Permit Application <br />