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• <br />F1 <br />SAN JOAQUIN COUNTY <br />(' �< ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />�q••.- NSP Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />�J1 0r <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 />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. cityistate/zip Linden, CA 95236 Phone <br />Cross Street Floor Rd. APN 093-440-02 <br />Property Owner' San Joaquin County Public Works Dept. Solid Waste Phone <br />Address 1810 East Hazelton Ave. City/State/Zip Stockton, CA 95205 <br />C-57 Contractor Yellow Jacket Drilling License# 643081 Phone <br />Address <br />9460 Lucas Ranch Rd. city/state/zip Rancho Cucamonga, CA 91730 <br />209-468-3066 <br />209-468-3066 <br />(909)989-8563 <br />Consultant CB&I License# Phone (619) 279-4251 <br />Address 1042 Willow Creek Road Suite A101 PMB 512 City/State/Zip Prescott AZ 86301 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />11,41�MONITORING <br />❑ <br />HOLLOW STEM <br />BORING DEPTH 26V ❑ BOLTED TRAFFIC BOX ® STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) <br />1) <br />HAMMERIDRIVEN <br />DIA. OF BOREHOLE 10" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />0 SOIL VAPOR PROBE 1 <br />❑ <br />MUD ROTARY <br />CASING THICKNESS 2" Triple Nest TYPE OF CASING: ❑ STEEL (M PVC ❑ OTHER <br />❑ SOIL BORING <br />❑ <br />PUSH POINT (GP/ CPT) <br />CONDUCTOR CASING ❑ Yes ®No Boring Oia: Casing Dia: Casing Depth: <br />❑ INJECTION (Au Snarae, Ozones <br />❑ <br />HAND AUGER <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE I@ PIPE <br />❑ OTHER <br />❑ <br />OTHER: <br />GROUT SEAL PUMPED? ❑ Yes I@ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs SG -2A <br />q 12 j Sa <br />SR0011'i�O�jO <br />GROUT SPECIFICATIONS Medium Bentonite Chips <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />L 7 MUSHROOM CAP 1713 feet below surface or feet below surface if >3 feet <br />r nereDy cerury that r am autnorrzea to complete tints application ana Gnat ine worK Will De cone in accordance wren <br />San Joaq 'n County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed ),_,.__PTitle/Company District Manager/ Yellow Jacket Drilling <br />Print Name Dean Coblish DateMarch 29, 2016 <br />�`5 DEPARTMENT USE ONLY <br />Application Accepted By: /"AjT��%4 J L[O A -D i A// 1-o VA Date Issued: `�/2­1 & ,APO <br />Grout Inspection By/Dates: , <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />/11d SAN JOA eu' . -- <br />HEA,L <br />FA Name I <br />FA Address I <br />WP Reviewed By <br />FA# <br />PR# <br />I Work Plan Uate Ir <br />FA PE <br />❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE <br />PE <br />Sc <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />SERVICE REQUEST# <br />INVOICE# <br />Work Plan <br />4.447 j <br />300 <br />f3o- <br />/5:c7 <br />q 12 j Sa <br />SR0011'i�O�jO <br />Permit <br />$130 x <br />(�Td. ff -)18'9s7 <br />EHD 29-01 6-23-2015 <br />Site Mitigation Well Permit Application <br />