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if,',star,* SANY]OAQUIN <br />;r j,y <br />�.•ii'rxotoc�" <br />4 <br />c COUNTY-, __ <br />14 <br />rLIL <br />Environmental Health Department <br />SITE MITIGATION WELL & BGRING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 953=7697 For 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 />City of Stockton ROW - E of S. CA St approx 25' & 100' on N side of E. Layette St. 209-937-8561 <br />- <br />Job Address t IgZno Z Dii CiZ1*" POrA CitylStatefZip Stockton, GA 95203 Phone <br />Cross Street S. California <br />Street <br />Property <br />APN <br />Owner' City of Stockton <br />None <br />Phone 209-937-8561 <br />Address 345 N. EI Dorado St. City/state/ztp Stockton, CA 95202 <br />C-57 Contractor Gregg Drilling License# C57A044456 Phone 925-313-5800 <br />Address 950 Howe Road City/state/Zip Martinez, CA 94553 <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. Licensefl PG #9716 Phone 209-522-4119 <br />Address 1172 Kansas Avenue City/State/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO 13E PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLIOW STEM BARING DEPTH 125 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />ElEXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 1.5 inches ❑ MULTIPLE CASINGS [IMULTI-LEVEL WELL CASING DIA <br />[ISOIL VAPOR PROBE ElMUD ROTARY CASING THICKNESS NIA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />IR SOIL BORING 0 m PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia. Casing Depth: <br />❑ INJECTION (Air sparge.ozone] ❑ HAND AUGER GROUT SEAL DEPTH 125 ft TREMIE TYPE TO BE USED: 171AUGERS ElHOSE 9 PIPE <br />ElOTHER ❑ OTHER: GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freetall Depth is 30 FI) <br />WELUSOIL BORING IDs CPT -15 & CPT -16 GROUT SPECIFICATIONS Neat Cement <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED [I AUGERS ❑ HOSE [I PIPE <br />COMMENTS: <br />Signed__, <br />Print Name G <br />DESTRUCTION METHOD: tCHE:CK 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 />I her by certify at t am authorized to complete this application and that the work vr11! be done in accordance with <br />�� San J�quln�oun Ordinance Codes and Standards, and all other applicable California laws.. <br />Application Accepted By:: <br />Grout Inspection BylDates: <br />Destruction Inspection By/Dates: <br />FA Name %jj1Q�' ;5 G� S Yya, FA Address 46 0 lC r' r��a FA# � 0 Z5 cj 2j PR# o � g'T <br />Facility/Site Information <br />Title/Company Vice President, Ground Zero Analysis, Inc. <br />Date_ r3 -- l '`'1 — �%. �N---. <br />FA PE WP Reviewed By -s` Work Plan Date a � <br />El C-57 [11 57 Authorization for Other to Sign Permit (3 Worker's Comp [I Workers Comp Waiver ncroachment Perm ❑ Access Agreement Lead Agency Approval MFR <br />COMMENTS/C(7NDITIONS: f Gr1 e <br />r7& kc .� r OO o"Yt T 0 `e <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />fel <br />Permitir $152 x j� ��,�% ��- Z yr Poo Lf 31 o <br />0 l �-o 95C>30 <br />1 868 E. Hazelton Avenue ( Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 www.Sigov.org/ehd <br />ww.sjgov.arg/ehd <br />EI -101294i 06-2e-21 Site Mitigation Well Permit Application <br />