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• <br />0 <br />` SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />`... P�` 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 209-468-3066 <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 Drillin L*. # 643081 <br />Address <br />Consultant <br />g rcense Phone <br />9460 Lucas Ranch Rd. city/state/zip Rancho Cucamonga, CA 91730 <br />CB&I <br />License# <br />Address 1042 Willow Creek Road Suite A101, PMB 512 City/State/Zip Prescott, AZ 86301 <br />209-468-3066 <br />(909)989-8563 <br />Phone (619)279-4251 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVelis Require Access Agreements or Encroachment Permits <br />TYPE OF WEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING ❑ HOLLOW STEM BORING DEPTH 26V ❑ BOLTED TRAFFIC BOX ® STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) M 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 IJ PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes IN No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Ar Saame.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes (D No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs SG -10A 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 fl Pt <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 feet <br />1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Shan Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed 99LJP � �p7s Title/Company District Manager/ Yellow Jacket Drilling <br />Print Name Dean Coblish DateMarch 29, 2016 <br />/ <br />,,/ � UCPAKIMENTU5EONLY / rTtc -IT/ <br />Application Accepted By: 00 #l'- } J Ll,t3 r ,�h ✓11 Date Issued: ���LfJ� �0 <br />Grout Inspection By/Dates: 'Z' Wi m'% � /� ~A ifs <br />Destruction Inspection By/Dates: y <br />Faci i /Site Information ti <br />FA Name FA Address I <br />FA PE WP Reviewed By I <br />IFA# - - PR# - <br />I Work Plan Date <br />❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Ap roval ❑ MFR <br />COMMENTS/CONDITIONS: Co-es+-�%f <br />,,// a <br />'l/"Q .-/.; Z,c.. ze- <br />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 />41L/7/ <br />300 <br />/3cl,-1//�` <br />QQ <br />Permit <br />$130 x <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />