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~"PQujN ; <br />SAN JOAQUIN <br />COUNTY <br />Greotne5S prows 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. 610 N . Hunter St. <br />Cross Street <br />Property Owner* Service First of Northern California <br />Address 102 W Bianchi Rd. <br />C-57 Contractor TEG -Northern California <br />Address 11350 Monier Park PI. <br />City/State/Zip Stockton, CA 95202 Phone <br />APN 139-060-33 <br />City/State/Zip Stockton, <br />CA 95207 <br />706568 <br />License# <br />Phone <br />Phone 916-853-8010 <br />City/state/zip Rancho Cordova, CA 95742 <br />Consultant/Sub-Contractor ATC Group Services LLC dba Atlas Technical License# <br />Address 1117 Lone Palm Ave., Suite 201 B <br />City/State/Zip <br />Modesto, CA 95351 <br />Phone <br />209-579-2221 <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 6 ft. ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />El EXTRACTION (Vapor/Water) ElHAMMER/DRIVEN DIA, OF BOREHOLE 2 In. ❑ MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />N SOIL VAPOR PROBE —�2❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL El PVC [I OTHER <br />[I SOIL BORING N PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes IM No Boring Dia: Casing Dia: Casing Depth: <br />El INJECTION (Air Sparge, Ozone) El HAND AUGER GROUT SEAL DEPTH 5 ft• TREMIE TYPE TO BE USED: ❑ AUGERS El HOSE [I PIPE <br />[I OTHER ❑ OTHER: GROUT SEAL PUMPED? El Yes N No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs SG -1 &S :2 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 171 AUGERS ED HOSE <br />MENTS: <br />Signed <br />Print Name <br />❑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 />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />� .1S� Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facilitv/Site Information <br />•�,►yz <br />Title/Company � 'Fv, ' .•t �,z <br />�_� � �f-�G Imo" � <br />o - <br />Date `��� L�'��ZZ- <br />- <br />� /1% <br />FA Name 0 (,�. FA Address <br />FA PE 7i�' �j /nWP Reviewed By J � Work Plan Date � g /2� <br />ElC-57�, C-57 Authorization for Other to Sign Permit El Worker's Comp El Worker's Comp Waiver [:1 Encroachment Permit El Access Agreement E] Lead Agency Approval El MFR <br />COMMENTS/CONDITIONS: ,cam 1J VVI rTfrk � �` L 9 FeV- �/ tll „& S ' 77 Z <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK#2 RECV'D BY L/z1/ZZ <br />DATE, A r(W1ELL PER(MIIT# pr INVOICE# <br />Permit Tlo5 3 13j$152 x 152 0139; �� v /z 1 // Z' 1 00 L 3 -1 0 l <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 <br />vvww.sjcehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />VV <br />vvww.sjcehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />