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t <br />SANIOAQUiN <br />---COUNTY— <br />S y!ta,s Frtrt <br />c: <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 andfor Instal 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/Zip Lodi, CA 95240 Phone <br />Cross Street Atkins Road APN 065 -12D -D4 <br />Property Owner' County of San Joaquin Phone (209) 468.3124 <br />Address 1810 East Hazelton Ave. Clty/State/Zip Stockton, CA 95205 <br />C-57 Contractor Cascade Drilling License# 938110 Phone (916) 638-1169 <br />Address 3000 Duluth Street City/State/Zip West Sacramento, CA 95691 <br />Consultant/Sub-Contractor <br />Address <br />License# _ <br />City/State/Zip <br />Phone <br />r'AY/jjejy7. <br />RECEIVED <br />CONSTRUCTION WORK TO QE PERFORMED: •Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />NUMBER <br />® MONITORING <br />1 ❑ <br />❑ EXTRACTION (VOWNaWl <br />❑ <br />❑ SOIL VAPOR PR08E <br />❑ <br />❑ SOIL BORING <br />❑ <br />❑ INJECTION (Air Spa -rat 02onel <br />❑ <br />❑ OTHER ❑ <br />WELD SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMERIDRIVEN <br />MUD ROTARY <br />PUSH POINT (GPI CPT) <br />HANDAUGER <br />OTHER: <br />_Zonis <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />-- - - - AUG 212o17 <br />BORING DEPTH 190' ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE SAN ENY7 A QLlry C <br />ou <br />DIA. OF BOREHOLE 1(r ® MULTIPLE CASINGS 13MLLTI LEVEL WELL CASING DIA HEALT-H �� E rq " <br />CASING THICKNESS SCH 80 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER T <br />CONDUCTOR CASING ❑ Yes ® No Boring Dia: 10' Cuing Dia: V&2" Cuing Deptir 190' <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED? ® Yes ❑ No (Nolle: Ma durum Freefatl Depth is 30 Ft) <br />GROUT SPECIFICATIONS Neat Camem <br />DESTRUCTION METHOD: ICHECK ALL THAT APP <br />❑ OVER -BORE DIAMETER of inches to depth of feel <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 heknnv errrfarw <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed 9 7*", Titiefcompany Regional Director / Cascade D filing L p <br />Print Name Ralph McGahey Date 8/16/2017 <br />r? DEPARTMENT IJSE ON <br />�.JLY <br />Application Accepted By: 1 % %9 z"a /&-y ,;,- 11iA 7E a✓. Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Fac)ift /Site Information <br />FA Name <br />FA Address <br />FA# <br />PR# <br />FA PE <br />WP Reviewed By <br />Work Pian Date <br />❑ C-57 ❑ G57 AulhodzeW <br />for Other to Sign Permit ❑ Worker's Comp ❑ Workees Camp waiver ❑ Encroachment Pemtil ❑ Axes Agreement ❑ Lead Agency Approval ❑ MFR <br />COM M ENTS/CONDITIONS: <br />WP TYPE I PE I SC <br />I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# <br />y y71 z �t / S�►e I /Sa1.Ul� G "7 SfZ®0?6 tis a <br />1868 E. Hazelton Avenue I Stockton, California 95205 ( T 209 468-3420 1 209 464-0138 1 www.sjcehd.com <br />EHD 29.0108-01-17 <br />Site hfiIigation Weil Permit AppRcaaat <br />