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SAN JUAQUIN <br />CauNTY <br />Greatness grows here. <br />Environmental Health Department <br />SITE MITIGATION WELL & BORING 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 />Job Address <br />Cross Street <br />1033 E Scotts Ave <br />S Union St <br />Property Owner* <br />Ycart Enterprises, LLC (Tracy Miller) <br />Address 646 S California St <br />C-57 Contractor Cascade Drilling, Rick Alcartado <br />ArlrirPcc 3459 Collins Ave <br />Consultant/Sub-Contractor <br />Address <br />City/State/Zip Stockton, CA 95205 Phone <br />APN 15128035 <br />City/State/Zip Stockton, CA 95205 <br />License# 1058336 <br />City/State/Zip Richmond, CA 94806 <br />License# <br />City/State/Zip <br />Phone 209-610-3059 <br />Phone 510-478-0858 <br />Phone <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 11 feet <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 inch <br />E] SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS <br />E SOIL BORING 2 _❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes El No <br />❑ <br />INJECTION (Air Sparge, Ozone) El HAND AUGER GROUT SEAL DEPTH <br />El OTHER El OTHER: GROUT SEAL PUMPED? El Yes [S] No <br />WELL/ SOIL BORING IDs 14 -B1 -SO, 14 -B2 -SO GROUT SPECIFICATIONS Neat cement <br />❑ BOLTED TRAFFIC BOX ❑STOVE PIPE <br />ElMULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TRE TYPE TO BE USED: ❑ AUGERS El HOSE El PIPE <br />(Note: Maximum Freefall Dgpth is 30 Ft) r <br />r <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: !CHECK ALL THaT APPLYI <br /># WELLS TO BE DESTROYED ❑OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs El PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS E:1 HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: DPT drilling of two 11 -ft deep soil borings for environmental soil sampling. <br />Analysis to include TPH-GRO, TPH-DRO/RRO, CAM -17 metals <br />Signed <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance wit <br />h <br />San J uin County Ordinance Codes and Standards, and all other applicable California laws. <br />,60444 1 A i Title/Company Regional Manager/Cascade Drilling <br />Print Name <br />Dustin Kin Date <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Faci <br />1 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T <br />EHD 29-01 04-04-07 <br />Date Issued: <br />209 468-3420 � F <br />209 464-0138 � www.sjcehd.com <br />Site Mitigation Well Permit Application <br />