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SAN j OA Q U I D Environmental Mealieh Department <br />— COUNTY__...__. <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 Inspektions <br />Application is hereby made to San Joaquin County for a permit to construct and/or instal the work described. <br />This application Is made In compliance with San Joaquin County Development Title. Chapter 94115.3. and the San Joaquin County Well Standards. <br />Job Address 17720 E. Harney Lane City/statolzipLod it CA 95240 Phone (284)887-3868 <br />Cross street APN 065-120-04 <br />PrapertyOwner` San Joaquin County PWD -Solid haste Phone (209)468-3066 <br />Address 1810 B. Hazelton Avenue <br />City/statelzip-Stockton, CA 95205 <br />C-sicontractor Gregg Drilling <br />Licensofl 485165 Phone (925)313-5800 <br />Address 950 Howe Road <br />Ctty/statelzip Martinez, CA 94553-3444 <br />Consul(ant/Sub-Contractor CB & I <br />Licensell C57485165 Phone (925)288-23g1 <br />Address 4005 Port Chicago Hwy <br />Citylstatelzip Concord, CA 94520-1180 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note- Offsite BoiingslWells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORiNG NUMDER INSTALLATION TYPE <br />CONSTRUCTION SPE Ti0 ",_;x� ,_I/ ' <br />D MONITORINGG-3E' ❑ HOLIOWSTEM <br />BORING DEPTN 0'__ ❑ BOLTED TRAFFIC BOX (Y) STOVE PIPE <br />❑ EXTRACTK)N(Vawiwatei) ❑ HAMMERIDRNEN <br />DIA.OFBDREHOLE 10° ❑ MULTIPLE CASINGS El MULTl1EVEL WELL CASING DIA lir <br />❑ SOILVAPORPROBE (@ MUD ROTARY <br />CASINO THICKNESS qrHAO TYPE OF CASING: ❑STEEL )PVC [3 OTHER <br />❑ SOILOORINO ❑ PUSH POINT (OPI CPT) <br />CONDUCTORCASNIG • ❑Yea ❑No BodngOfe: Wing Dia: Casing0epih: <br />❑ INJECTION (Nrspame,Must ❑ HANDAUGER <br />GROUT SEAL DEPTH TREMIETYPE TOBEUSED: ❑AUGERS ®HOSE ®PIPE <br />❑ OTHER OTHER: <br />GROUT SEAL PUMPED? 6a Yes E3 No (Note: Maximum Frearall Depth h 30 FQ <br />�.0 <br />WELUSOILSORING IDs; A(33�9 C� Sig <br />water manit•nrino <br />GROUTSPECIFICATIONS Neat cement <br />DESTRUCTION WORK TO BE PERFORMED: <br />R WELLS TORE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />Print Name <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -GORE DIAMETER of Inches to depth of_ <br />❑ PRESSURE GROUT To depth of feel bebw surface <br />❑ EXPLOSIVES From to feel below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or _ feet below <br />located on the west side of North County Landfill. <br />and Standards, and all other applicable California laws. <br />TitlelCompany W J ^) e4s* C r <br />DEPARTMENT USE ONLY <br />Application Accepted By: de�'r' �2 •0�7�+-,�i�fl,-G Date Issued: <br />Grout Inspection BylDatos: _ <br />Destruction Inspection By/Dates: <br />Faa I 9 to lnforlR§tlon <br />so / / <br />feet <br />FA Name <br />FAAddreas <br />FAN I <br />PRfI <br />FA PE <br />WP Reviewed By <br />Work Plen Dale <br />❑C57❑C57AulhoduLlonrot War toson Permit ❑WoWsComp E3Worka(ecamp WeNer 13Ewoachmea1Pomil E3AomsAgreeneni ❑LeadAgemyApproval ❑MFR <br />60MMENTSICONDITIONS: - <br />jVVPTYPEj <br />PE <br />I SC <br />I FEE INFO <br />JAMT REMITFEDI <br />CHECK# <br />I RECV'D BY <br />I DATE I <br />WELL PERMITII <br />INVOICEII <br />Permit <br />313 <br />152 x3% <br />g q U <br />1888 E. Hazelton Avenue I Stockton, Calf nla 952061 T 309 468.34201 P 209 404-013$ 1 www sio".com <br />EHM4108411-17 Ske Mlrga on WdlPormltAppleavon <br />