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1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />Environmental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 City/State/Zip Phone <br />Cross Street APN <br />Property Owner* Phone <br />Address City/State/Zip <br />C-57 Contractor License# Phone <br />Address City/State/Zip <br />Consultant/Sub-Contractor License# Phone <br />Address City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING HOLLOW STEM BORING DEPTH BOLTED TRAFFIC BOX STOVE PIPE EXTRACTION (Vapor/Water) HAMMER/DRIVEN DIA. OF BOREHOLE MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE MUD ROTARY CASING THICKNESS TYPE OF CASING: STEEL PVC OTHER SOIL BORING PUSH POINT (GP/ CPT) CONDUCTOR CASING Yes No Boring Dia: Casing Dia: Casing Depth: INJECTION (Air Sparge, Ozone) HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: AUGERS HOSE PIPE OTHER OTHER: ____________ GROUT SEAL PUMPED? Yes No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED OVER-BORE DIAMETER of _______ inches to depth of ________ feet <br />WELL IDs PRESSURE GROUT To depth of ________ feet below surface <br />GROUT SPECIFICATIONS EXPLOSIVES From ________ to ______ feet below surface <br />TREMIE TYPE TO BE USED AUGERS HOSE PIPE MUSHROOM CAP 3 feet below surface or ________ feet below surface if >3 feet <br />COMMENTS: <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 />Signed Title/Company <br />Print Name Date <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br /> C-57 C-57 Authorization for Other to Sign Permit Worker’s Comp Worker’s Comp Waiver Encroachment Permit Access Agreement Lead Agency Approval MFR <br />COMMENTS/CONDITIONS: <br />_____ <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152 x <br />Stockton, CA 95203 <br />See figures <br />209-946-0246 <br />209-946-0246Port of Stockton <br />2201 West Washington Street Stockton, CA 95203 <br />Penecore Drilling 906899 530-661-3600 <br />220 N. East Street Woodland CA, 95776 <br />Geosyntec Consultants N/A 510-836-3034 <br />1111 Broadway 6th Floor Oakland CA, 94607 <br />2 <br />Approximately 7 ft <br />Type I/II Portland CementSS-817B-6A; SS-817B-7A <br />Kimberly Brandt <br />Senior Geologist/ Geosyntec Consultants <br /> 16203007 <br />1200 Humphreys Street (see figures) <br />3.7 inches <br />June 16, 2022