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i1 S A N 10 A Q U A Environmentdl Health Department h COUNTY cyCrpoRr'�P' Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 8606 Thornton Road City/State/zip Stockton, CA 95209 Phone Cross Street Davis Road APN 072-420-19 Property Owner* Gian Singh Phone Address 1557 Lincoln Rd. City/State/zip Yuba City, CA 95993 C-57 Contractor Gregg Drilling, LLC License# 1044456 Phone (925) 313-5800 Address 950 Howe Rd. City/State/zip Martinez, CA 94553 Consultant/Sub-Contractor ATC Group Services LLC License# Phone (209) 579-2221 Address 1117 Lone Palm Ave., Suite 201 B City/State/zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 ft. ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 4 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSparae,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 10 ft. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs SS1-SS4 GROUT SPECIFICATIONS meat Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [_1AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company_ '�c (�(E i C A Print Name SC 0. Date (? Q 3 11 K DEPARTMENT USE ONLY Application Accepted By: / Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name �'`'`�`� bz- FA Address <ir,. x FA# 0OZ5 PR# 105_to-�,o 1t3WVt7 'T1W i- FA PE )AtJ'0 WP Reviewed By X Work Plan Date 1.2,0 �y j ❑C-57 52f657 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement [LPread Agency Approval 10 MFR COMMENTS/CONDITIONS: I I WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 5� ,�1-3 $152 x 11 1 1. 1� lri it��t;3�1ti�11 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD j-'Q1 08-01-17 5 j 7 •u) It j T�i 1—-� Site Mitigation Well Permit Application