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SAN JOAQUIN ' COUNTY G/t'�J�rlt SS 11'0tvs t1,31�_. Environmental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES � YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards, Job Address 622 E. Lindsay Street and 601 E. [diner Avenue Cross Street N. Stanislaus Street P* State of Californ ia roperty Owner Address 707 3rd Street, 5th Sloor C-57 Contractor Geocon Consultants, Inc. Address 3160 Gold Valley Drive Cons ulta nt/Sub-Contractor Address City/State/Zip stockton, cA s52o2 A P N 139-310-250 Phone vacant Phone City/State/Zip West Sacramento, CA 95605 License# 716050, exp. 12/31/23 7 R/12 6_ 57 phone City/State/Zip Rancho Cordova, CA 95742 License# City/State/Zip Phone 916-375-4125 916-852-9118 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (VaporMater) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE 1.51n ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 7 to 14 ❑ MUD ROTARY CASINGTHICKNESS 0.25 in TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER nylaflow ❑ 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) WELL/ SOIL BORING IDS SV7/SV7A through SV14/SV14A GROUT SPECIFICATION After sampling, tubing will be removed from temporary vapor wells and the 1.5 inch borehole will be overdrilled with 2.25 inch direct push drill rods. Borings will then be backfilled with cement grout. DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED DESTRUCTION METHOD: (CHECK ALL THAT APPLY) WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED El AUGERS [I HOSE [:1 PIPE COMMENTS: E Print Name ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface f-1 MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet hereby certify that I a authorized to complete this application and that the work will be done in accordance with 7 a Ordinance Codes and Standards, and all other applicable California laws. Title/Company Project Manager, Geocon Consultants, Inc. Nicole Hastings -Bethel Date go Grout Inspection By/Dates: IN M 01 A Destruction Inspection By Far-ility/Site Infnrmatinn FA Name 1868 E. Hazelton Avenue ( Stockton, California 952051T 209 468-3420 j F 209 464-0138 1 www.sjcehd.com EHD 29-01 OS -01-i7 /~ � 4 0 57 ��rr�S•R�/\ FA PE Zn WP Reviewed By TVV Work Plan Date 6 Z010ZZ -57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval MFR COMMI TS/CONDITIONS: - a � �-� d lev .ten Y— S�Tc WP TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit D� 1213 1$152 x 3 C C JVJ �pA IOC143 3 Site Mitigation Well Permit Application