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SAN JOAQUIN <br />i COUNTY <br />Environmental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All 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 />622 E. Lindsay Street and 6Q1 E. t4iner Avenue <br />Cross Street N. Stanislaus Street <br />State of Californ <br />Job Address <br />ia <br />Property Owner - <br />Address 707 3rd Street, 5th Sloor <br />CCGeocon Consultants, <br />Ed ontractor <br />Inc. <br />Address 3160 Gold Valley Drive <br />Cons u Ita nt/Sub-Co ntracto r <br />Address <br />City/State/Zip <br />Stockton, CA 95202 <br />vacant <br />Phone <br />APN 139-310-250 <br />Phone <br />City/State/Zip West 916-375-4125 <br />Sacramento, CA 95605 <br />License# 716050, exp. 12/31/23 32 IY117 � phone 916-852-9118 <br />City/State/Zip Rancho Cordova, CA 95742 <br />License# Phone <br />/State/Zi <br />p <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 1.5 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />® SOILVAPOR PROBE 7 to 14 ❑ MUD ROTARY CASING THICKNESS 0.25 in TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER nylaflow <br />❑ SOIL BORING ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDS SV7/SV7A through SV14lSV14A GROUT SPECIFICATION After sampling, tubing will be removed from temporary vapor wells and the 1.5 inch borehole will be overdrilled / <br />with 2.25 inch direct push drill rods. Borings will then be backfilled with cement grout. / <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 E3PIPE <br />COMMENTS: <br />Sig <br />Print Name <br />I hereby certify that I <br />Nicole Hastings -Bethel <br />Application Accepted By: _ <br />Grout Inspection By/Dates: <br />Date Issued: <br />Destruction Inspection ByA <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 />to complete this application and that the work will be done in accordance with <br />Bance Codes and Standards, and all other applicable California laws. <br />Title/Company Project Manager, Geocon Consultants, Inc. <br />Date <br />� n � t )DEPARTMENT USE ONLY <br />1868 E. Hazelton Avenue � Stockton, California 95205 J T 209 468-3420 � F 209 464-0138 � www.sjcehd.com <br />EHD 29-01 08-01-17 �.��ry1���N� #� D � �' 8 Q 'L- 3 2 � Site Mitigation Well Permit Application <br />