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tvry <br />,�s SALMONEnvironmental Health DepartmentcoUNTY <br />Greaoiess 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 6484 N Waverly Rd. City/State/Zip T,in(Ien'ICA 999-16 Phone 7-3969 <br />Cross Street - APN 09344002 <br />Property Owner* S TC: PWD - Solid Waste Phone 468-3066 <br />Address 1820 E.- Hazelton Ave. City/State0p Stockton/CA/95205 <br />C-57Contractor CrPah Drilling License# 485165 Phone 925-313-5800 <br />Address950 Howe Rd cityistate/zip Martinez/CA/94553 <br />Consultant/Sub-Contractor CB& I License# LGH00 7 Phone 99.5-298-9181. <br />Address 4005 Portchicago Hwy cityistate/zip Concord/CA/94520 <br />CONSTRUCTION WORK TO BE PERFORMED. *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />IX MONITORING ❑ HOLLOW STEM BORING DEPTH 322 F t . ❑ BOLTED TRAFFIC BOX ® STOVE PIPE J / <br />❑ EXTRACTION (Vapormater) ❑ HAMMERMRIVEN DIA. OF BOREHOLE 10 Ft . — ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA 2.5 <br />❑ SOILVAPORPROBE MUD ROTARY CASINGTHICKNESS SCh 90 TYPE OF CASING: [I STEEL IS(PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING❑Yes [I No Boring Dla: Casing Die: Casing Depth: <br />El INJECTION (Ak Soame, ozone)❑ HAND AUGER GROUT SEAL DEPTH 2V7 7 TREMIE TYPE TO BE USED: KI AUGERS ❑.HOSE ❑ PIPE <br />❑ OTHER 1m OTHER:,. o n i_ c GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum freefall Depth is 80 Fl) <br />WELUSOILBORING IDs _MW -4.A, GROUT SPECIFICAnONsNeat cement <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED Q OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs []PRESSURE GROUT To depth of feet below surface - <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED Q AUGERS ❑ HOSE Q PIPE El MUSHROOM CAP Q 3 feet below surface or feet below surface if>3 feet <br />COMMENTS: MW -4A is located north of the landfill. MW -7 is located southeast <br />of the landfill. <br />r- .. _;)heteti'�ce t�ia�iam'authoriieiLto'cotriplef�i<iiisappll�atioiiar�iithat�tNetx/orkiiyilth�doh�inab�or�ianceiniitFi• -• _ <br />San a n.Eoun Ordinance Godes and Standards, and all o'E_ lap c b e California laws _ _ _ _ <br />Signed~ Y» Title/Company San Joaquin County -Solid Waste <br />Print Name Ta i M . Bahadori' Date <br />DEPARTMENT USE ONLY , <br />Application Accepted By: <br />Grout Inspection By/Dates: 1 <br />Destruction Inspection By/Dates: <br />3/' 7 <br />Facilitu/Sita lnfnrmation <br />FA Name <br />FA Address <br />FA# <br />PR# <br />FA PE <br />WP Reviewed By <br />Work Plan Date <br />E3 C-57 1] C-57 Authorizagon for Other iaSign Permit ❑ wortuat's comp ❑ Worker's Camp Waiver ❑ Emoechment Pen1Yt ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />3 cy t. i�.'y-. �- � 4 d -T �S� ` �-r � <br />INP TYPE <br />' PE <br />SC. <br />I FEE INFO <br />JAMT REMITTEbj <br />CHECKN <br />I RECv'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />yv71 <br />3% 3 <br />152x 1 <br />1,52 <br />✓�' si" <br />tb <br />� !; <br />1868 E. Hazelton Avenue I Stockton, California 95205'1 T 209 468-34201 F 209 464-0138 1 www.,gjcehd.com <br />vun 9o.na Mnl-97 Sita Milloation Well Permit Acollealion <br />