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F <br />SANt..IUAQUIN <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 Motirs Adva=6 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 TIUe, Chapter 9.1116.3, and the San Joaquin County Well Standards, <br />Job Address 17720 E Harney Lane City/StatelZip Lodi, CA 95240 Phone <br />Cross Street Atkins Road APN 066-120.04 <br />Property Owner* County of San Joaquin Phone (209) 468.3124 <br />Address 1810 East Hazelton Ave, City/State/Zip Stockton, CA 95205 <br />C-57 Contractor Cascade Drilling_ License# 938110 Phone (916) 638-1169 <br />Address 3000 Duluth Street City/StatelZlp West Sacramento, CA 95691 <br />Consultant/Sub-Contractor License# Phone <br />Address <br />Cilwstatelzip <br />-,Ay— <br />CONSTRUCTIONWOf2it TO BE <br />PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits' <br />DTIE OF WELLIBORING NUMBER 1119ALLAT10N TYPE CONSTRUCTION SPECIFICATIONS 011 <br />® MONITORING 1 Q - HOLLOW STEM BORING DEPTH 190, ❑ BOLTED TRAFFIC BOX El STOVE PIPE�R p Lrk coot <br />Q EXTRACTION (VaporANaler)Q HAMMERIDRNEN DIA. OF BOREHOLE 1()o 10 MULTIPLE CASINGS ❑ MULTI-LEVELMLL CASING DIA R� 7N cE 1- <br />Q SOIL VAPOR PROeE C) MUD ROTARY CASING THICKNESS SCH 80 TYPE OF CASING: El STEEL 19 PVC 0 OTHER � T�Iy7 <br />Q SOIL BORING 13 PUSH POW (GP/CPT) CONDUCTOR CASING Q We ® No Bating Dia: IV Casing Dia. 1' & 2' Casing Depth: IW <br />0 INJECTION(kIMLOrsllsl E] HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [3 AUGERS L7 HOSE f3 PIPE <br />OTHER: <br />Q OTHER ❑ -2oidc GROUT SEAL PUMPED? ® Yes 13 No {Note: Mexhum Freefag Depth is 30 fq <br />WELD SON. BORING IDs. GROUT SPECIFICATIONS Neat Cement <br />DESTRUCTION WORK10— BE PERFORMED: DESTRUCTION METHOD: (CHECK & TiiATAPQLYt <br /># WELLS 70 BE DESTROYED ® OVER -BORE DIAMETER of Inches to depltl of feet <br />WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />® MUSHROOM CAP Ll 3 Feet bebw surface or fent hnim sr idarn <br />GROUT SPECIFICATIONS <br />t nereoy cenny that I am autnot zea to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordlnance Codes and Standards, and all other applicable California taws. <br />signed OA`s Tille/Company _ _ Regional Director J Cascade Drilling L P <br />Print Name IWl h McGahey Date 811612017 <br />[7 DEPARTMENT USE ONLY <br />Application Accepted By �liy �'9 �J rs Q ; QE's Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facllit /Site Information <br />FA Name <br />FA Address <br />FA# <br />PR# <br />FA PE <br />WP Reviewed 8Y <br />Work Plan Dab <br />❑ C.s7 f 3 C-57 Authorization for Olher to Sign Pa dt Q Wakefs Comp Q Watkafs Caigi Wainer D Erdtoachment Pe rrA ❑ Access Agreemmai ❑ Lesd AgeacyApprovol Q MFR <br />GOMMENTSICONDITIONS I <br />JWPTYPEJ PE I Be FEE INFO AMT REMITTED CHEGK# REGV-1)BY I DAT' WELL PERMIT# INVOICE# <br />1868 E. Hazelton Avenue I Stockton, California 95205 j T 209 468-3420 i 209 464-0138 j www.sjcehd.com <br />EtiD 29-ei 08Af •iT <br />Site <br />h%gatWn Well Permit Apperason <br />