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E <br />SAN IOAQUIN <br />lr ,. <br />—COUNTY ---- <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 herebymade 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 Tltte, Chapter 9-1115.3, and the San Joaquin County Well Standards <br />Job Address 17720 E. Harney Lane <br />city/StatelzipLodii CA 95240 Phone (204887-3868 <br />Cross street <br />APN 065-120-04 <br />Propertyowner* San Joaquin County PWD -Solid Waste Phone (209)468-3066 <br />Address 1810 E. Hazelton Avenue <br />C(tylstatelz(p.Stockton, CA 95205 <br />C-57 Contractor Gregg Drilling <br />Ltcensefl 485165 Phone (925)313-5800 <br />Address 950 Howe Road <br />cltylstatelzlp Martinez, CA 94553-3444 <br />Consultant/Sub-Contractor CB & I <br />Mansell C57485165 Phone (925)286-2381 <br />Address 4005 Port Chicago Hwy <br />City/8tatelzip Concord, CA 94520-1180 <br />CONSTRUCTION WORK TO BE PERFORMED: "Note: OHsl(e Sorings/Welis Require Access Agreements or Encroachment Permits <br />TYPE OF WELUOORI NUMBER INSTALLATION TYPE <br />CONSTRUCTION SPECT 4' U /="- <br />19 MONITORING f C —3$ 13HOLLOWSTEM <br />BORING DEPTH 12��- (3 BOLTED TRAFFIC BOX RI STOVE PIPE <br />❑ EXTPACTION(VaporlWelet) ❑ HAMMERMRRIEN <br />DIA.OFBOREHOLE 1011❑MULTIPLECASINGSCIMULTILEVELWELLCASINGOIA 211 <br />O SOILVAPOR PROBE 6d MUD ROTARY <br />CASING THICKNESS SCH AO TYPEOFCASING: ❑STEEL 5UPVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GPI CPT) <br />CONDUCTOR CASINO' ❑ Yes ❑ No BodnilDle: Casing via: Casing nepne <br />❑ INJECTION (&irSnuao.Ozone) ❑ HANOAUOER <br />GROUTSEALDEPTH TREMIETYPE TOBEUSED: 13 AUGERS ®HOSE ®PIPE <br />❑ OTHER ❑ OTHER: <br />GROUTSEALPUMPED? lia% ❑No (Nolo., Maximum FreefallDepth Is30F1) <br />�'3�L <br />WELUSOILBORINGiDs �— i 0 ' <br />mater manif•aring <br />GROUTSPECIFICATION9 Neat Cement <br />DESTRUCTION WORK TO BE PERFORMED: <br />g WELLS TOBE DESTROYED <br />WELL We <br />GROUT SPECIFICATIONS <br />I WSW 49rlVv1 at I am aut . e - <br />Signed_ <br />Print Name <br />DESTRUCTION METHOD: rCHECKALLTHAT APPLY) <br />❑ OVER BORE DIAMETER of Inches 10 depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feel below surface <br />and Standards, and all other applicable California laws. <br />Tille/Company e! A) Gdw*a%t Y <br />Date 4424 24 % 7 <br />DEPARTMENT USE ONLY <br />Application Accepted By: r' O J'S+-. r/6rG Date Issued: <br />Grout Inspection BylDates: 96—� <br />Destruction Inspection BylDates: <br />aollitylelleInformatfors. <br />FANams <br />FAAddress <br />I <br />I FAIL I <br />PRN <br />FA PE <br />WP Reviewed By <br />Werk Pian Date <br />OC -57 ❑C57Aathafragonfor0lherloSignPerMt ❑WodcelaComp ❑WoAtaraCanpWaNer ❑EhuoachmenlParmT ❑AuessAtnanent ❑LeadAgencyApprgyt ❑MFR <br />COMMENTS/CONDITIONS: <br />IWIPTYPE1 <br />PE <br />1 SC <br />1 FEE INFO <br />1111TREMITTEDICHECKOIRIEWIDDY1 <br />DATE I <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />Yy %t <br />31 <br />152 X <br />I <br />I <br />I <br />I <br />�;J 37 g <br />18813 E. Hazelton Avenue I Stockton, CoNfomis 952051 T 209 468-34201 F 309 404-0138 1 www.sjcehd.com <br />EHD2a-016941-17 Site MlrgegonWon P Applkaron <br />