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SAN JUAUUIN <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 />Z4 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 1036 E Sonora St <br />Cross Street S Union St <br />Property Owner* <br />Address <br />Alfonso Ocampo <br />C-57 Contractor Cascade Drilling, Rick Alcartado <br />Address 3459 Collins Ave <br />Consultant/Sub-Contractor <br />Address <br />CitylState/Zip Stockton, CA 95205 <br />APN 15126034 <br />CitylState/Zip <br />License# 1058336 <br />CitylState/Zip Richmond, CA 94806 <br />License# <br />Q+ +^17; <br />Phone 209-910-0655 <br />Phone N/A <br />Phone 510478-0858 <br />Phone <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 11 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 Inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑x SOIL BORING _3 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) f <br />WELL/ SOIL BORING IDs 9 -131 -SO, 9-62-S0, 9 -133 -SO GROUT SPECIFICATIONS Neat cement N ? <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE <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 />iCOMMENTS: DPT drilling of three 11 -ft deep soil borings for environmental soil <br />sampling. 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 with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />��t7 /t.�t Title/Company Regional Manager/Cascade Drilling <br />Print Name DUStIn Kin <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date <br />Date Issued <br />III <br />E...jzelton 209 68-3420 F 209 464 135 V��s]4hd.com <br />1868 Avenue � Stock on, Ca lfo Ini953h� T � <br />EHD 29-01 04-0 <br />FA Name <br />�- � <br />� <br />FA Address <br />a► <br />FA# <br />FA PE <br />A <br />`� <br />WP Reviewed By <br />Work Plan Date <br />'S�, "\L��Z <br />11 7 ❑ C-57 Authorization <br />for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment <br />Permit VAccess <br />Agreement ❑ Lead Agency Approval <br />VFR <br />COM ENTS/CONDITIONS:r7 G fi �, <br />it 1M QJp� 4 uoai Lkbte o)k <br />beg Ono <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMT(TED <br />CHECK# <br />RECV''AD�BY <br />DATE <br />PERMIT# <br />INVOICE# <br />Permit <br />C � <br />$1 <br />Jl <br />--i� <br />p �WPELL <br />Vv ` o 0geZ405 " <br />4-07 Site Mitigation Well Permit Application <br />