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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> 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 r <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 gounty Development Title, Chapter 9-1115.3, and tpe San Joaq (n County Well Standards. <br /> � � Cit'¢ C0$p �ACre.cltlwtd"Pr-r"wo £Pjq-23Zo-) <br /> Job Address 2085 _I Street C �,�,�KC.. Clt /tS�tpa�tte(ZI Stockton, CA 95205 Phone <br /> Cross Street C tr�ef- M a i n APN _ 753-102-100-000 j <br /> Pr u o merica Inc OC IA/ Phono <br /> 360-594-7978 <br /> BP <br /> Property Owner � 1�V <br /> Address 4 Centerpotn rive 200 Clty� La Palma, CA 90623 <br /> C-57 Contractor 93 0 S 1 { CR �/Licenny#I� i9- JOSS-J Phone 916-638-1169 <br /> Address 3000 DULUTH ST. �V`u'1 ,IA r M"tyGIty/State Zip W. CRA E TO, CA 94691 <br /> ConsultantlSub-Contractor Antea Group USA, Inc. License# 548062 Phone 562-206-2556 <br /> Address 11010 White Rock Road, Suite 140 City/State/Zip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings Walls Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M MONITORING 2 ® HOLLOWSTEM BORING DEPTH 50ft M BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Waler) ❑ HAMMERNRNEN DIA.OF BOREHOLE Hin ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS 2 inch dla. TYPE OF CASING: [I STEEL 19PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING [I Yes ®No Boring Die: Cwlfg Dla: Casirg Depth: <br /> ❑ INJECTION(Atspemeomnet ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETO BEUSED: MAUGERS [I HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes []No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELUSOILBORINGIDs 9W-5, MW-6 GROUT SPECIFICATIONS Hydrated bentonite chip transition seal. t , <br /> Portland Cementer 40 efrB o fit i <br /> or A f& use s-Ki� <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALi;i APPLYI <br /> #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of—Inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel belay surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> _San Joaquin County Ordinance Codes and Standards, and all other applicable California laws.-- <br /> Signed Title/Company Project Manager / Antea group <br /> Print Name Manuel Padilla Date 11/18/2019 <br /> D ARTMENT USE ONLY I I <br /> Application Accepted By: Date Issued: 20 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> t_ <br /> Facilit /Site Information <br /> jName AAddress ZD�� � ,J a jn FA# QQ Z� Z,r PR# o5—qs /� ' <br /> WP Reviewed By Wodc Plan Date g /g 7, C-RAutlherzatonl"Other lo Sign Permit ❑WorkersComp ❑WorkersGompWaiver ❑EncroachmentPermit ❑AaessAgreement ❑Lead Agemy Appreval ❑MFR <br /> _ IEA� rP° t� ��►A s or � rise. E - ; � �JCOMMENTSONS: r J ( O tA)6rL <br /> wJIIIIAf� V• <br /> cl.L <br /> 12_tt1I O� <br /> P TYPE PE SC FEE IN AMT REMITTED ECK# I kECV`D BY r DA E . WELL <br /> /PERMIT# INVOICE# <br /> Permito $152X ,13 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-M 0801-17 Site Mingato Wefl Permit Appliranan <br /> S 12eo gl SO4' <br />