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,, , ot„M � 10AQUIN <br /> Environmental Health Department <br /> Iat ;: --COUNTY— <br /> �'�' 'Xot'� Greatness grows here. <br /> oa. ' <br /> SITE MITIGATION <br /> BA�TION Wtl fob' & BORING PERMITontaminant APPLICATION emediaation <br /> For Wells a Inspections NON-REFUNDABLE PERMIT EXPIRES ired For All SUED <br /> 48 Hours Advance Notice Required <br /> and the San Joaquin County Well Standards. <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. <br /> RiponiCAl95366 Phone — <br /> This application is made in compliance with San Joaquin County Development lSteie Chapter 9-1115 Z <br /> 210 S Stockton Ave APN 209-599-21D8 <br /> Job Address Phone — <br /> cross Street tsl Street RiponlCAl95366 <br /> Property Owner` Darryl Bartels CitylStateZip Phone 916-368— <br /> Address <br /> 210 S.Stockton Ave License# 938110 <br /> CitylStatelZip West SacramenlolCA.9569 510-495-5105 <br /> C-57 Contractor Cascade Drillin Technical Services phone — <br /> Address 3000 Duluth Street License# <br /> ConsultantiSub-Contractor Haley&Nddch, Inc. <br /> CitylStatelZip OaklandICAl94612 <br /> Address <br /> 1956 Webster Street, Suite 300 <br /> CONSTRUCTION ts <br /> WORK TO BE PERFORMED: 'Note: OHsile BoringslWells Require Access Agreements or Encroa❑cSTovE PIPE <br /> hment rmI <br /> NS <br /> � BOIdNG DEPTH 255fee��MULTEIPLECA ZINGS❑MULTbLEVELWELLCASINGDIA- <br /> TYPEOFTYPEOFW r NUMBER❑ IT LLOWSTEMN TYPE CONSTRUCTION SPECIFICATIO <br /> ❑ MONITORING ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2 TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER Casing DeP� <br /> ❑ EXTRACTION(VaporANaler) 1 SVP ❑ MUD ROTARY <br /> CASINGTHICKNESS NIA Casing Dia: <br /> E3 SOILVAPOR PROBE TREMIETYPETO REUSED: ❑AUGERS ❑HOSE I]PIPE <br /> ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring D : � <br /> GROUT SEAL DEPTH Yes ❑Ho (Nole:Msrarum Franiall DePlh is 30 TO <br /> ❑ SOIL BORING ❑ HANDAUGER GROUT SEAL PUMPED? IZ <br /> [ILA INJECTION P— °'"Aet ❑ OTHER <br /> ❑ OTHER GROUT SPECIFICATIONS <br /> WELL/SOIL BORING IDS V - <br /> DESTRUCTIONMETHOD: CHECK ALL THAT Aes to depth of�feel <br /> ❑OVER-BORE DIAMETER ci <br /> DESTRUCTION WORK TO BE PERFORMED: feet below surface <br /> ❑PRESSURE GROUT Fob�0=to—feetbeio <br /> #WE w surface <br /> LLS TO BE DESTROYED ❑EXPLOSNES feel below surface if>3 feet <br /> WELL IDS MUSHROOM CAP ❑3 feetbelow surface or <br /> GROUT SPECIFICATIONS <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE <br /> COMMENTS: <br /> Ordinance Codes and standards,and all other applicable California laws. <br /> I hereby certify that I am authorized to complete this application and that the work wrll be Hale &Aldrich,Inc. with <br /> San Joaquin County Title1Company Project Manager, Y <br /> Dale 21312020 <br /> Signed rr-1 <br /> Pdnt Name Cheyenne Wa �/� <br /> PARTMENT USE ONLY Date Issued: <br /> Application Accepted By: 1 <br /> / 0 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: FA# 00 Z! t L1q PR# <br /> Facilit ISite information FAAddress Z� IAS r "� { <br /> NeS 19A <br /> FA Name � Wodc Plan Dale a HA I � <br /> n WP Reviewed By Access Agreement ❑Le ge Approval MF <br /> FA PE (, 1 � `� WmkersGomP War ❑E°a0 �nl Permit ❑ <br /> hon 1or00er to Sign Permit ❑Wohers Come S <br /> ❑057 ❑G-57Aulhodra' 00 1 <br /> COMMENTSIC,p1 NDITIONL'S 7 Jk f �f'l �I <br /> "5� 03JL Mom" INV CE <br /> V t WELL PERMIT# <br /> Y� AM REMITTED CHECK# RECV'D BY DATE ', r { <br /> PE sc FE NFO 7 l� Yv 00� ✓ D <br /> WP TYPE 6 C- !/ VVWW.sicehd.corn <br /> Permit no t 3 $152 X 209 46 F 209 464-0138 � <br /> P� <br /> T 8-34201 site M.. I mAPPI'Muen <br /> 1868 E. Hazelton Avenue i Stockton, California 952051 5 l <br /> EHn 29010"147 <br />