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OPOI Illy I, I ...) <br /> SAN�tJOA'Qd N Environmental Health Department <br /> —COUNTY— <br /> `�i,,,�oa 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 near 8606 Thornton Road city/State/zip Stockton. CA 95209 Phone <br /> Cross Street Davis Road APN <br /> Property Owner' City of Stockton Public Works Department Phone 209-937-8486 <br /> Address 22 E. Weber Ave. city/state/zip Stockton, CA 95202 <br /> C-57 Contractor Cascade Drilling License# 1058336 Phone (916) 638-1169 <br /> Address 3000 Duluth St. city/state/zip West Sacramento, CA 95691 <br /> Consultant/Sub-Contractor ATC Group Services LLC License# Phone (209) 579-2221 <br /> Address 1117 Lone Palm Ave., Suite 201 B citylstatelzip Modesto, CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: [I STEEL[I PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION rAY Sparta Ozone) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 3 ®OVER-BORE Ij$A DIAMETER of 8 inches to depth of45-110feet <br /> WELL IDSMW6 MW7. MW9 ❑PRESSUREGROUT Todepthof feet below surface <br /> GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ®AUGERS El HOSE [I PIPE El MUSHROOM CAP ❑3 feel below surface or feet below surface it>3 feet <br /> COMMENTS: .rr4*Wte- t4r4ircdV 1 30 4x Cq <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> S Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company �j7L [. rouro Serui cAs <br /> Print Name M / Date 10 Ol j!Z n Za <br /> DEPARTMENT USE ONLY Q <br /> Application Accepted By: Ve Date Issued: B /1 2 /Zo 2-6 <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information / <br /> FA Name o'�� C,IC1e Kosl�1 FA Address Q6p 6T( arink� FA# pp Z3�-I'�' PR# Ds�l'38} <br /> FA PE 60 WP Reviewed By !v� Work Plan Dale <br /> ❑C-57 CS7 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Camp Waiver ❑Encroachment Pemtit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSIC NDITIONS: <br /> WP TYPE �PEj SC2 FEE INFO AMT RlEMITTED C/HIECyK`# RECV'D BY DATE WELLµPERMIIT# INVOICE# <br /> Permit 'Z KfZ j17 $152x 3 'f� -f 6G� �� �'�� VV"W <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 v cehd.com <br /> END 29-01 0e-01-17 site Mgigarion Well Permit Application <br />