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• 0 <br />RECElYffiAOAQUIN Environmental Health Department <br />15 101 <br />OUNTY <br />GieOlness.grows here. <br />'E'R'Iju��1.,,��FE;�.jjITIGATION WELL & BORING PERMIT APPLICATION q-'6116 °t'1 <br />PERIJl1TN�l��llfls9vl <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 Tide, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 6484 N. Waverly Road CitylstatelzlpLinden/CA/95236 Phone 209-887-3969 <br />Cross street N/A APN 0934_4002 <br />Property Owner* San Joaquin County PWD—Solid WaatP Phone <br />Address 1810 E. Hazelton Avenue City/statetzip Stockton, CA 95205 <br />C-57 Contractor Pitcher Drilling Company License# 263085 Phone <br />address 218 Demeter Street City/State/Zip East Palo Alto-,-CA-94303 <br />Consultant/Sub-ContractorGeo—Logic Associates, Inc. License# <br />650-328-8910 <br />Phone 916-771-7904 <br />Address 4190 Douglas Boulevard, #250 City/Statelzip Granite Bay, CA 95746 <br />CONSTRUCTION WORK TO BE PERFORMED: *Nate: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />E3 MONITORING <br />❑ HOLLOW STEM <br />BORING DEPTH 900 VT ❑ BOLTED TRAFFIC BOX ❑ STOVE PPE <br />❑ EXTRACTION (vapodwater) <br />❑ HAMMERIDRNEN <br />DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTHRAL WELL CASING DIA <br />iii SOIL VAPOR PROBE <br />MUD ROTARY <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />SOIL BORING <br />❑ PUSH POINT (GP/ CPT) <br />CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION I&smrae. ozone) <br />❑ HAND AUGER <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS)WHOSE gPIPE <br />❑ OTHER <br />❑ OTHER: <br />GROUT SEAL PUMPED? 29 Yes O No (Note: Maximum Freelall Depth Is 30 Ft) <br />WEWSOILBORING IDs; <br />4/ <br />G4 . 4 64 B2• <br />GROUT SPECIFICATIONS Neat cement <br />I FHL WO j�!TREmnTED1 CHECK# RECV'D BY <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUTS <br />TREMIE TYPE TO <br />lop <br />Signed l <br />Print Name <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 17713 feet below surface or feet below surface <br />and Standards, and all other applicable California laws. <br />Title/Company San Joaquin County -Solid Waste <br />11 -to -17 <br />DEPARTMENT USE ONLY <br />�� <br />Appltcation Accepted By: 1 <br />/r�,�� L; � J 21.d313 -J � !�/�� ✓J� o Date Issued: <br />Grout Inspection By/Dates: v'%S'�-' ��/ i I —7 <br />Destruction Inspection By/Dates: <br />F2rllltu1Rlra lninrmaflnn <br />FA Name <br />FA Address <br />JFA#: <br />E460DVS-)"71 <br />FA PE <br />WP Reviewed By <br />Work Plan Date <br />OC -9 O G57Aulakdon trOlwrlIsV t Fendt O Workers Comp ❑ Workers Comp Waives ❑ Encroadunenl Perm@ O Access Agresrnent ❑ Lead AVWApprovai ❑ MFR <br />CO ONDn'lONS: 16 L4 a x..2 o&y-v's, 1W. S r� P 4 <br />/gC r 0 rf �.ns.. y r' �4�� +S f ' i`s c, <br />/7o r ." r2 2 + — 9 it �,...,,t o2.2 r .,r <br />All, X-4 r y "`' 6 [- s� ez 7'; �� <br />` e� r`as % 2,6 <br />JWPTYPIEJ <br />PE I SC <br />I FHL WO j�!TREmnTED1 CHECK# RECV'D BY <br />DATE I <br />WELL PERMITax <br />INVOICE# <br />Permit <br />qq- 343 <br />152Xr tifll 3 <br />!I l� <br />f„SPad 7& �5 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29.0108-01-17 Site Millgatlon Well Permit Applicalion <br />