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pUl!. <br /> SALMON Environmental Health Department <br /> h—COU NTY— <br /> �O� r % Greatness grows here. <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 /> Job Address 2121 N Zuckerman Rd CItylStatelzip Stockton/CA/9520(Txhone <br /> Cross Street McDonald River Bridge APN 12 12 j7_qaZL)0j fV-r V;Otr'. rr. <br /> Property Owner' PG&E Phone <br /> Address 6121 Bollinger Canyon Rd city/StatelZip San Ramon, Ca 94583 <br /> C-57Contractor Gulf Shore construction Services, Inc. License# 964224 Phone 916-939-4117 <br /> Address 3362 Fitzgerald Rd City/State/Zip Rancho Cordova, CA 95742 <br /> ConsultanNSub-Contractor Kleinf elder License# Phone 209-948-1345 <br /> Address 2001 Arch Airport Rd, Suite 100 city/statelzip Stockton, CA 95206 <br /> CONSTRUCTION WORK TO BE PERFORMED: `Note: ONsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM BORING DEPTH 50 ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapon/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 66 III❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE MUD ROTARY CASING THICKNESSSchedule 40 TYPE OF CASING: ❑STEELXPVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING El Yes ❑No Boring Be: Casing Dia: 2 in Casing Depth: bO i <br /> ❑ INJECTION(4 so".ozonel ❑ HANDAUGER GROUTSEALDEPTH 0-15 TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes JdNo (Note:Maximum Freefall Depth Is 30 Fp <br /> WELU SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES From to_feet bet <br /> TREMIE TYPE TO BE USED El AUGERS El HOSE El PIPE ❑MUSHROOM CAP 1­13 feel belay surface or feet belay surface if>3Ye <br /> COMMENTS: 1 <br /> I hereby certify that I am authorized to complete this application and that the work will a done n accordance with <br /> G San Joaouin.County Ordinance Codes and Standards,and all other applicable fornia laws. j <br /> Signed_ k`�`�o` � � Title/Company Staff Geologist Kleinfelder <br /> Print Name Megan Porter Date 5/22/2020 <br /> DEP ARTMrENT USE ONLY <br /> Application Accepted By: t <br /> Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information p I I <br /> FA Name W /„as FA Address Z � (� Y'�.L� FA# oOZ� o It PR# A q <br /> FA PE 2 - WP ReAewed By � � Work PlanDate "Q <br /> ❑C37 57MENTS/CONDITI �! <br /> Authonralbn for Other to Sign Permit ❑Workeescomp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Leand/Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: µ �A �. ., 4O1Vb W $A � devfS /-e�� pf v S l 1 (ply j/n Z , li ►uu cl[S�I / _ <br /> WP TYPE PE SC FEE INFO AMT REMITITED1 CHECK# I RECV'D BY AT WELL PEFfMIT# INVOICE# <br /> Permit b $152 x 1 15 2- CC I 1W I q1VINI WY00 00 l <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 2ed108-01-17 Sit ifigaun Wen Perno��� Ccauon Lw e <br />