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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> i <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 South Corral Hollow Road CitylStatelZip Tracy/CA/95376 Phone <br /> Cross Street n/a APN 25114007 <br /> Property Owner` California Department of Fish and Wildlife Phone (916)445-0411 <br /> Address 1416 9th Street citylstatelzip Sacramento/CA/95814 <br /> C-57 Contractor Gregg Drilling and Testing, Inc. License# C57 485165 Phone 925)313-5800 <br /> Address 950 Howe Road citylstatelzip Martinez/CA/94553 <br /> 1 <br /> Consultant/Sub-Contractor License# Phone <br /> Address CitylStatelZip <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLA71ON TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VamMaler) ❑ HAMMER7DRIVEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(OR CPT( CONDUCTOR CASING ❑Yes ❑No Boring()is Cung Da: Cwig Depth <br /> ❑ INJECTION(M SPUN,on" ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note Maximum FmIaN Deptll is 30 Fill <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO SE DESTROYED three f31 ®OVER-BORE DIAMETER of 1 O-1 S Inches to depth of 27-49 feel <br /> WELL IDS W-25D-02 W-2513-01'W-25M-01 ❑PRESSUREGROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS neat Cement ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED EIJI A RS ❑HOSE ®PIPE MUSHROOM AP ❑3 feet below surface or feet below surface it>3 feel <br /> COMMENTS: - noi­ <br /> �� D.SI 7I Q Cad CL. <br /> hereby certify that 1 am author zed to complete s applicand hate work will be done In accordance with `�P <br /> San Jo n County Ordinance Codes and Standards,and a I ther applicable Cali ornfa laws. 1. <br /> Signed Title/Company <br /> Print Name Date Zi34J t <br /> DEPART EN SE ONLY I/jS <br /> Application Accepted By: Data Issued: /21 <br /> A. F ;T�QA <br /> Grout Inspection By/Dates; <br /> Destruction Inspection BylDates: VYI-5-r— —% <br /> FacillImIS11a Information IJ <br /> FA Name ✓+u^CvtJ. FAAddress Sv 'L^ ,rv�A K+4a� 1Ut FA# OfY 2- PR# �5 lob <br /> s1tL.Jg') <br /> FA PE �,SL i WP Reviewed By L. X Work Plan Oate <br /> ❑Cb7 s7Aufjwnsm(or CtWIo%nPemW &IJ ,❑Workers Comp Waver ❑Enaoac s Agreemenl ead AgMApgova EKFR <br /> COMMENTSICONDITIONS:rI_ a <br /> � t5� <br /> jVVPTYPEj FEE INFO AMT REMITTED CHECK# RECYD BY DATE WELL PERMIT# INVOICE# <br /> Permit 2 U I— 3 1_3 152 x 3 LC U� L - LY \,J \P t10 3& <br /> 1868 E Hazelton Avenue Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 vwwW'sjcehd com <br /> EHD 29-01 0901-1T Sae Mtgaim Wen Pamn Apouton <br /> use Ms S�3 (�iJ 445-16 RUM L—x 919'01I2 sV-, C`.'ci . <br />