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SANc10AQuIN Environmental Health Department <br /> fx —COUNTY— <br /> � <br /> .O,1jmn1 \Y Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PER EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> unty for a permit to construct 1and/or115.3 install the work described. <br /> Application is hereby made to San Joaquin Co <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 8606 Thornton Road citylstatelzip Stockton CA 95209 Phone <br /> APN 072-420-19 <br /> Cross Street Davis Road Phone <br /> Property Owner Glan Singh citylstatelzip Yuba Cit CA 95993 <br /> Address 1557 Lincoln Rd. License# 1058336 P �11 i e, Iz!Phone (916) 63 <br /> 8-1169 <br /> C-57 Contractor Cascade Drilling <br /> City/State/Zip West S2cramento CA 95691 <br /> Address 3000 Duluth St. Phone (209) <br /> 579-222 <br /> ConsultantiSub-Contractor ATC Grgoq S@NICE:S LLC C11ty1StatelZip Modesto CA 95351 <br /> Address 1117 Lone Palm Ave. Suite 201E <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF OF W� NUMBER INSTALLATIONTYPE CONSTRUCTION SPECIFICATIONS ❑BOLTEDTRAFFICBOX ❑STOVEPIPE <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CARING DIAL <br /> ❑ EXTRACTION NaPorM'aler) ❑ HAMMERNRNEN DIA.OF BOREHOLE, Ty PE OF CASING: ❑STEEL❑PVC [I OTHER <br /> ❑ SOILVAPOR PROBE <br /> ❑ MUD ROTARY CASINGTHICKNESS Casing Dia: Casing Depth: <br /> ❑ Boring a <br /> SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING GROUT SEAL DEPTH yes []NoREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ HAND AUGER <br /> ❑ INJECTION far 5^'0 aaI ❑ OTHER: GROUT SEAL PUMPED? ❑Yes El No (Note:Ma>umum Freefall Depth is 30 F <br /> ❑ OTHER GROUT SPECIFICATIONS <br /> WELD SOIL BORING IDs <br /> DESTRUCTION METHOD'(CHECK ALL THAT APPLY <br /> DESTRUCTION WORK TO BE PERFORMED: ®OVER-BOREtt$A DIAMETER of 8 Inches to depth of30-111feet <br /> #WELLS TO BE DESTROYED 17 feet below surface <br /> WELL IDsMW1-MW5' MW8 & MW-10- OS1-OS8' SVE1-SVE200EXPLOSVESRD� From <br /> lo—feetbelaysudace <br /> GROUT SPECIFICATIONS neatcement MUSHROOM CAP ❑3 feet below surface or feet below surface It>3 feet <br /> TREMIE TYPE TO BE USED ®AUGERS HOSE ❑PIPE >3O t b� <br /> COMMENT S: tvnlNl2- <br /> I hereby certify that I am authorized to complete this application and that the work w ill be done in accordance with <br /> S n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Title/Company t5 l au, <br /> Signed Date <br /> Print Name <br /> 1=.PARTMENT USE ONLY p /� A0 <br /> Date Issued: O <br /> Application Accepted By: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dales: 2 <br /> Faciill /Site Information FA# O0Z3 It PR# 0 <br /> FAName �,, W � o8��1 FAAddress 60 6 -t'h0rnk�n <br /> s""-- �`rL � � Work Plan Date <br /> _o WP Reviewed By <br /> FA PE _2A 1 tY1 <br /> �,�;5 to Other to Sign Permit ❑Workers Comp ❑Workers Come Waiver ❑Encroachment Permit ❑Access ggmemenl ❑Lead Agency Approval MFR <br /> [I C.57 7 AuNodzagon <br /> COMMENTSICON DITIONS: <br /> WP TYPE PE SC $152 xEE INFO AMT�ITT�ED CHf;!� RECV'D B D%�� oo L Pi ROM�T# INVOICE# <br /> Permit p'L 3i3 V 1�fU41 8 � 4 3 cehd.com <br /> s Site Mitigation Well Permit Application <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 46B-3420 1 F 209 461-013 I www.sl <br /> EHD 29ol 08-01-17 <br />