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1 <br /> o IN.c SAN JOAQUIN COUNTY <br /> Y �t •,o� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> :'�'"�' � � •/ 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> \Icon - <br /> a��: Telephone: (209) 468-3420 Fax: (209) 468.3433 Web: www.sicehd.com <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 /> Application is hereby made to San Joaquin County for a pennit 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 3081 North Tracy Boulevard Citylstate/zip Tracy/ CA / 95376Phone ( 415 ) 617-5791 <br /> CrossStreet West Clover Road APN 214-180-41 <br /> Property Owner` Loia Tracy LLC Phone ( 415 ) 617-5791 <br /> Address 3439 Brookside Road #108 citylstate/ZipStockton/ CA / 95219 <br /> C-576ontractorEnvironmen-cal Control Associates License# 695970 Phone (831 ) 662-8178 <br /> Address 3011 Twin Palms Drive City/State/zip Aptos / CA / 95003 <br /> Consultant/Sub-Contractor Partner Rngineerinq and science, Zne.Lleense# Phone ( 661 ) 316-8237 <br /> Address 2154 Torrance Boulevard City/State/zip Torrance / CA / 90501 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsAVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 81 ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION NaporWauu) ❑ HAMMER/DRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> N SOIL BORING —t4 PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes MNo Boring Dia Caslrg D'a: Casing Depth <br /> ❑ INJECTION I*Saame.0o.- ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED'+ ❑Yes ❑No (Nate:Maximum Freefall Depth is 30 F) <br /> WELD SOIL BORING IDs GROUT SPECIFICATIONS Neat Cement <br /> B32 through B36 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ` "9r up." Comp a on of ❑OVER-BORE DIAMETER of—inches to depth of feet <br /> WELLIDs B32 throuah B36 El PRESSURE GROUT To depth of_feet below wrfaca <br /> GROUT SPECIFICATIONS Neat Cement ❑ EXPLOSIVES From_to_feet below surface <br /> TREAIIE TYPE TO BE USED ❑AUGERS ❑HOSE [j]PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> ^ ' I hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with <br /> N ` n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Sri1`u`r J Title/Company ;,,:,o: vxotec: ea:v:e: a anc science. = <br /> Print Name Debbie Soukup Date February 21 , 2017 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: �-- / Date Issued: '3 6:Fj / I T <br /> Grout Inspection By/Dates: L_ -k �{' 1,2 1 <br /> Destruction Inspection BylOates: <br /> FacilitarlSite Information <br /> FA Name yps rvI S FAAddress I Ay'T (�., .0 FAR 002- PRO 0 Z <br /> FA PE 1-01" WP Reviewed By Work Plan Date <br /> 71057 0C-57 Authorization for Other to sign Pvmil ❑Workers Comp ❑Workers Comp Waive- ❑Encroachment Pszmit ❑Access Agreement ❑Laid Agancy Approval ❑MFR <br /> COMMENTSIC ONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 2903 S Z3 113911( +3 4 t'I 1L) 31T 9f I7 S6L C7 01 1 01� <br /> Permit 2k fl$ 31 5Xx 3 Li 11 111 � 31 1 S 00-11013 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />