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l <br /> SAN JOANN I'nvironmental Health Department <br /> COIJN I Y <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRE" 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 comFFliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> So. side of E. Main St. between Adelbert Ave. and <br /> Job Address S. Gertrude Ave. City/Statel2lp Stockton, CA 95215 Phone <br /> Cross Street Adelbert Ave. APN N/A <br /> Property Owner* San Joaquin County Public Works Dept. Phone 209-468-3000 <br /> Address 1810 E. Hazelton Ave. city/Slate/zip <br /> C-57 Contractor Grogg Drilling LLC License# 1044456 Phone 925-313-5800 <br /> Address 950 Howe Road cityistateRlp Martinez, CA 94553 <br /> Consultant/Sub-Contractor ATC Group Services LLC License# -Phone 209-579-2221 <br /> Address 1117 Lone Palm Ave., Ste. 201E CItylStatelzlp Modesto, CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: OBsite Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORINO NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Cl MONITORING ❑ HOLLOW STEM BORING DEPTH 115 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaperWater) ❑ HAMMERIORNEN DM.OF BOREHOLE 4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC O OTHER <br /> 91 SOIL BORING 2 M PUSH POINT(GPICPi) CONDUCTOR CASING ❑Yes [9No Wdng 01¢ CesIAd Die: CWIV DOPIII: <br /> ❑ INJECTION INrsoam.01 n ❑ HAND AUGER GROUT SEAL DEPTH 115 THEME TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> ❑ OTHER ❑ OTHER;__ GROAT SEAL PUMPED? ❑Yes ®No (Note:MaAmum Freelall Depth Is 30 FQ <br /> WEWSOILBORINGIOs GROUT SPECIFICATIONS neat cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(CHECKALL TIIATAPPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Inches to depth of feel <br /> WELL IDs ❑PRESSUREGROUT To depth of__feel below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From__to_feet below surface <br /> TREMIE TYPE TO BE USED El AUGERS [I HOSE Q PIPE [I MUSHROOM CAP ❑3 feet below surface or feel below surface if>3(eel <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete lhIs application and that the work will be done In accordance with <br /> San' Joaquin County Ordinance Cc rise and Standards,and all other applicable California laws. <br /> Signed !�L! Title/Company .y_ .G� <br /> Pdnt Namo .�// Date <br /> ay DEPARTMENT USE ONLY /� /� <br /> Application Accepted By: Date Issued: •� <br /> Grout Inspection By/Dales:. <br /> Destruction Inspection By/Dates: <br /> Fac Ill ISI a Information 1 nG <br /> FAName J0. � FA Address N'0b Ma ;o FA# M PR# 05 3`k <br /> FA PE ZQ 0 WP Reviewed By Work Plan Date <br /> C57 ❑c-57Authod2uUmforONerlo Sbn Permit ❑WoMrs Comp ❑Wohers Comp Waiver ❑Encroachmenl Perna ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: G 4(,V 4l i /i �� _ p �e)r C' t11�to <br /> �41 A } �r � id„e� <br /> WP TYPE PE SC I FEE IN AMT RoE'MCITTED CHECK# I RECV'D BY I DATE I WELL PERMIT# I INVOICE# <br /> Permit '1?051 go $162 x �L, 1 304 IMINI2 0 0 s'k <br /> 1868 E. Hazelton Avenue I Stockton, California,95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2e-01 UMi-17 SIIe MIeg.ve.We a It Apprwlion <br /> SRo� stg�� <br />