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i SAN JOAQUIN Environmental Health Department COUNTY— SITE MITIGATION WELL St 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 Applicallon Is hereby made to San Joaquin Countypermit to construct and/or install the work described.for P bed. . This application is made In compliance with San Joaquin County Development Title,Chapter9-1115.3,and the San Joaquin County Well Standards. Job Address 720 W. Weber Avenue CRy/StateMp Stockton/CA 195203 Phone N/A Cross Street N. Lincoln Street APN 13737001 Property Owner' E.J. Williams Property Management Phone 209-473-4022 Address P.O. Box 7185 City/StaterAP Stockton/CA/95267 C-57 Contractor Cascade Drilling License# 1058336 /NOS/30 &1 Phone 916-638-1169 Address 3000 Duluth Street Citylstate/Zip West Sacramento/CA/95691 ConsultaM/Sub-Contractor Tr1hydro. Com. License# -N/A Phone(520) 730-1442 Address 2520 Stanwell Drive, #105 Citylstate/L P Concord./CA/94520 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offslle Bodngs8MIls Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapuMaler) ❑ HAMMERATRNEN DLA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASH/ ❑Yes ❑No Bonus Ift Cadno Dla: Ca"Depth: ❑ INJECTION rasom..ome.r ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER; GROUTSEAL PUMPED? ❑Yes ❑No (Note:Madnum Freefal Depth is 30 FB WELL!SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT App Yt #WELLS TO BE DESTROYED 2 E ®OVER-BORE DIAMETER of 4 hches to depth of 9 feet WELL IDs APSV-9.APSV-10 ❑PRESSUREGROtIT To depth of_feet belowsurface GROUT SPECIFICATIONS NB at Cement Grout ❑EXPLOSIVES From_to_feelbelowsudace TREMIE TYPE TO BE USED AUGERS HOSE PIPE [I MUSHROOM CAP ❑3 feet below surface or feel below surface it s3 feel OMMENTS; - _ I hereby certify that I am authorized to complete this application and that the work will be done in accordance with an quip C ul Ordinance Codes and Standards,and all other applicable Calif rma laws. Signed �� TftlelCom By �+cEee..t'a 1'W /TR wK h F -c� Print Na lad/ �1cHr,1 (.qQ-F„� _ Date ` 7105— 1 RTMENT USE ONLY Application Accepted By: Date Issued: ! ,6 C..✓ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili S" In Irmon FA Name /d.N v �b�V�Y P�IIA FA Address FA# bZ3 S/ 6Z PR# o0i 6�4 FA PE L QGD K I WP Reviewed By Work Plan Date'? 0C-57 i C57AutWriothnnffaOberto Sign Penh (:]Workers Comp ❑Workerscmnp Wahor ❑Emma;hmemPomik ❑Access Asreemenl ❑LeadAgercy Appmva ❑MFR COMMENTS/C N TIONS: WP TYPE I PE I sC FEE INFO AMT REMITTED CHECK# I RECV'D BY DATE WELL PERMIT# IN VOICE# Permit 152 x / 2 16 he W?m 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-342011 F 209 464-0138 1 www.sjcehd.com EHD 48-01 Oea1-17 11 3$9M�1_ �am MfaJlpy o*mi Appiwtlon