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r <br /> f � <br /> SAN 10AQUIN Environmental Health Deent <br /> COUNTY wt <br /> E0VE <br /> AUG 13 <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATIONy 2018 <br /> For Wells and Borings Used for Contaminant Investigations and RemediatiorpRoiMfzw <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fRM/TiS�R�EES4Cry <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application Is hereby made to San Joaquin County fora 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 32727 South Corral Hollow Road Citylstate2ip Tracy/CA/95304 Phone (925)449-1023 <br /> Cross Street n/a APN 25113002, 511200 25112004 <br /> Property Owner` Kevin RrUeCkner Phone (619)938-8277 <br /> Address P.O. Box 488 citylstatefzip ak id /CA/92040 <br /> C-67 Contractor Gregg Drilling and Testing, Inc. License# C57 485165 Phone (925)313-5800 <br /> Address 950 Howe Road city/stateizip Martinez/CA/94553 <br /> ConsultsmUSub-Contractor License# _ Phone . . <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: OUsite BoringsfVVells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELDBORINO UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORINGDEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporWater) ❑ HAMMERIDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS MULTILEVEL WELL CASING D(A <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING. ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPr CPT) CONDUCTORCASING ❑Yes ❑No Boring Die Cashg Dla: Casrg Depth <br /> ❑ INJECTION Uarswo owe t ❑ HANDAIIGER GROUT SEAL DEPTH TREMIE TYPE TO BE USER. ❑AUGERS ❑HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER __. GROAT SEAL PUMPED? [I Yes ❑No (Note Madmum Fmelaa Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED one(1) ®OVER-BORE DIAMETER of-,-14 inches to depth of 2_feet <br /> WELL IDs W-2 4P-o3 ❑PRESSUREGROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS IT <br /> cement - ❑EXPLOSIVES From_to_feel below surface <br /> TREMIE TYPE TO BE USED AUGERS HOSE 0 PIPE ❑MUSHROOM CAP ❑3 feet be law surface a feel betmv surface if>3 feet <br /> COMMENTS: <br /> hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Jq q In County Ordinance Codes and Standards,and all other applicable California laws. <br /> J `� <br /> Signed The/Company R QF U Lwmaa uv"At6le. <br /> PrintName Dale 6t <br /> DEPA ENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection BylDales: <br /> Destruction Inspection By/Dates: <br /> Facilltv/Site Information <br /> I <br /> FA Name ` � � �� FA Address O' � {{n t4wJ P44 FA# OvyLu <br /> PR# <br /> FA PE I . ;)-[t gq I WP Reviewed By L X Work Plan Date <br /> ❑G57 W<57 AudW;ta§mror ONerto Sign Permit EWorkers Ccmp ❑Werkefs Carp Waiver ❑Encroachment Pemel cress Agreement L�I'IRal Agency Apgoval FR <br /> CO�MENTS ONDITIONS: <br /> +I re <br /> a&4 N (4 :s e Q <br /> jWPTYPEI PE I SC FEE INFO JAMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br /> Permit 1 Z`laL 1313 152x ► ltis , VrLgd LX 9-Will wP003$1LO <br /> 1868E Hazelton Avenue l Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwW Sjcehd corn <br /> EHD 29-0108-01-17 sne M wafon Well Permit APpIc w <br />