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SAN10AQUIN Environmental Health Department <br /> —COIJNTY— <br /> <igroi�l� Greolness 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 Joaquln County fora permit to construct and/or Install the work described. <br /> This application Is made in compliance wllh San Joaquin County Development Title,Chapter 9-1116.3,and the San Joaquin County Well Standards. <br /> Job Address 112l MoCloy Avenue City/StatelZip Stockton/CA195203 Phone (209)946-0246 <br /> Cross Street Port of Stockton Expy APN 162-003-07 <br /> Properly owner- Port of Stockton Phone (209)946-0246 <br /> Address 2201 West Washington Street City/StatelZip Stockton/CA/96203 <br /> C-57 Contractor Gulf Shores License# 964224 Phone (816)949-1012 <br /> Address 3362 Fitzgerald Rd. CltylStatelZip Rancho Cordova/CA/94596 <br /> Consultant/Sub-Contractor Haley&Aldrich,Inc. License# Phone (025)949-1012 <br /> Address 2033 N Main St UNIT 309 CltylStatelZip Walnut Ofeek/CA194696 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: OHsite BoringsAlVells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING M HOLLOWSTEM BORINGDEPTH 10,20.KW504 ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaparMaler) ❑ HAMMERIDRNEN DIA.OFBOREHOLE 3.251n.1e19. :OMULTIPLECASINGSp MULTI-LEVELWELLCASINGDIA <br /> SOILVAPORPROBE ❑ MUD ROTARY CASINGTHCKNESS NA TYPE OF CASING: [I STEEL [I PVC ❑ OTHER <br /> ID SOILBORING 10 ❑ PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes ®No Bodng Dla: Casing Dia: Cadrg DepW: <br /> ❑ INJECTION tAispene.easel M HANDAUGER GROUTSEALDEPTH TREMIETYPETO BE USED: ❑AUGERS ❑HOSE IKIPIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEALPUMPED7 ©Yes [I No (Note:Masknum FreeraVDeplhls3OR) <br /> WELUSOILSORINGIDs HS -0HS 1,NSA-/f$,HSA-12,HSA43,HSA45 GROUT SPECIFICATIONS oa Ulatir out <br /> A �l— <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THATAPPLYI <br /> #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of feel <br /> WELL IDs ❑PRESSURE GROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_lo_feel below surface <br /> THEME TYPE TO BE USED El AUGERS El HOSE [I PIPE ❑MUSHROOM CAP [13feelbaowsurfaceor feel below surface if>3 feet <br /> COMMENTS: Borings will be advanced with hand auger to 6 feel and by hallow stem auger from 5 itto Iota]depth of the boring. <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance codes and Standards, and all other applicable California.laws. _ <br /> Signed W;� Title/Company Assistant Project Manager/Geoleglsl/Haley&Aldrich <br /> Print Name Adam Piestrzenlewicz Date 815120 <br /> D PARTMENT USE ONLY <br /> Application Accepted By: Date Issued: f 3 40 <br /> G>r4 Inspection By/Dates: 1�/r7- Z6'2'0 <br /> Destruction Inspection BylDates: <br /> aclllt /Site Information <br /> /+ �p <br /> FA Name S(-re, 4�- � FAAddress ` 121 MCI. O FAN D0ZZZ!;M PR# <br /> FA PE 29 S VIP Reviewed By Work Plan Date <br /> 0057 C57AuIJ&WUon1or ONerloSlmPsmQ ❑fakers Cro�mp ❑Workes OompWawer ❑rlEncroachment Permit ❑Access Agreemonl [I Lead AgewyAppfool ❑MFR <br /> COMMENTS/ DITIONS: 5146A91-t• a S ey- dIs +0 i{// FAr- W6 Sf����� L Lh3 <br /> S k ck�+t� Mv4FFs : A sa6MI w,It b b , 1 CW70slT i,>sMII rafp <br /> WP TY E PE SC FEE INFO AMT RE91MITTED1 CHECK# I RECVD BY I DATE WELL PERMIT# 14414vollCE# <br /> Permit O $152x .<2 C LIW D1.S-t:V S <br /> 1868 E. Hazelton Avenue i Stockton. California 95205"if <br /> I T 209 468-3420 1 F 209 464-0138 i www.sjcehd.com wit. <br /> EHD 294108 01-17 I 1 Z 1 $ i I Site Miggetion Well Penult Application <br /> 5(Z006z`+b I <br />