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1 0 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />�`: '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <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. City/state/zip Linden, CA 95236 Phone <br />Cross Street Floor Rd. APN 093-440-02 <br />Property Owner" San oaquin 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 />Consultant <br />9460 Lucas Ranch Rd. citylstate/zip Rancho Cucamonga, CA 91730 <br />CB&I License# <br />Address 1042 Willow Creek Road Suite A101, PMB 512 City/State/Zip Prescott, AZ 86301 <br />209-468-3066 <br />1 ' - .'1:MIMIT'i <br />(909)989-8563 <br />Phone (619)279-4251 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING ❑ HOLLOW STEM BORING DEPTH 196' ❑ BOLTED TRAFFIC BOX ® STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) >ftl HAMMER(DRIVEN DIA. OF BOREHOLE 10" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />® SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS 2" Triple Nest TYPE OF CASING: ❑ STEEL (M PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes N No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Ak sprue ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [j Yes ® No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL] SOIL BORING IDs SG -6A GROUT SPECIFICATIONS Medium Bentonite Chips <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS n HOSE I-1 PI <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 />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />an J cluin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed �.� Title/Company District Manager/ Yellow Jacket Drilling <br />Print Name Dean Coblish DateMarch 29, 2016 <br />Application Accepted By: a & 4.0" A"I Ato ✓4 Date Issued: <br />Grout Inspection By/Dates: 75- <br />Destruction Inspection By/Dates: ti � WIZ <br />Facility/Site Information oe4l'„tit' <br />FA Name ( <br />FA Address I FA# 1 <br />WP Reviewed By <br />PR# <br />I Work Plan Date <br />FA PE <br />❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMM�+ENTSICONDITIONS: /9 X ( <br />19+�H� -- bar,.—.1� ce�k,.v� / •.� r . �v`-��� <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 />60 <br />/ 3CI— <br />�1 <br />Permit <br />$130 x <br />EHD 29-01 6-23-2015 <br />Site Mitigation Well Permit Application <br />