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SAN®JOAQUIN p <br />„ Environmental Health Department <br />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 17720E Harney Lane City/state/Zip Lodi, 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-57 Contractor Gregg Drilling License# 485165 Phone (925) 313-5800 <br />Address 950 Howe Road City/state/zip Martinez, CA 94553-3444 <br />Cons ultant/Sub-Contractor CB & I License# C57485165 Phone (925) 288-2381 <br />Address 4005 Port Chicago Hwy CRY/State/Zip Concord, CA 94520-1180 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />® MONITORING G 1 R ❑ HOLLOW STEM BORING DEPTH 1 9;' <br />❑ BOLTED TRAFFIC BOX 91 STOVE PIPE <br />[I EXTRACTION (Vapor/Water) [IHAMMERIDRIVEN DIA. OF BOREHOLE 10 ' [I MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA 211 <br />❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS SCH 80 TYPE OF CASING: ❑ STEEL IS PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS M HOSE ® PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? M Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GIB GROUT SPECIFICATIONSNeat 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 />GIB is located on the East side of North County Landfill. <br />r nerec <br />ordinance <br />other applicable California laws. <br />Signed t! P-/.Title/Company <br />yam,/ Title/Company gn33 rngq CnUnty <br />Print Name `/Ff {-' (• 1J,+00,oO Date ( p <br />// ,,tDEPARTMENT USE ONLY <br />Application Accepted By: Y c �L' t� Date Issued:/T22 <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />I <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 />AMT REMITTED <br />CHECK# RECV'D BY <br />DATE <br />PERMIT# <br />INVOICE# <br />Permit <br />qq7 <br />31.� <br />$152x <br />nWELL <br />1868 E. Hazelton Avenue I Stockton, Californiaa 95105 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />