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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greotness 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 <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 SWANSON ROAD City/Staterzip MANTECA/CA/95337 Phone N/A <br /> Cross Street WEST YOSEMITE AVENUE APN 198 17 008 ADAr iA4 jq0 -ifo <br /> Property Owner' CITY OF MANTECA CGS I� "0 D Phone 209-456-8400 <br /> Address 1001 W CENTER STREET city/State/zip MANTECA. CA 95337 <br /> C-57 Contractor TABER DRILLING License# 969927 Phone 916-371-8234 <br /> Address 536 GALVESTON STREET Citylstatelzip WEST SACRAMENTO/CA/95691 <br /> Consultant/Sub•senbseterBSK ASSOCIATES License# 490942 Phone 925-315-3151 <br /> Address 399 LINDBERGH AVENUE Citylstatelzip LIVERMORE/CA/94551 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 1 E HOLLOWSTEM BORING DEPTH 35 FT ■BOLTEDTRAFFICBOX OR NSTOVEPIPE <br /> ❑ EXTRACTION(VaporM/aler) ❑ HAMMERJDRIVEN DIA.OF BOREHOLE 10 inches ❑MULTIPLE CASINGS MULTREVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS SCH PVC 4OTYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes NNo Boling Oia: Casing Dia: 4lnches Casing Depth: 12 FT <br /> ❑ INJECTION(Am,ime Ozanel ❑ HANDAUGER GROUT SEAL DEPTH 10 FT TREMIETYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? []Yes 0No (Note:Maximum Freefdl Depth is 30 Ft) <br /> WELU SOIL BORING IDS MW-1 GROUT SPECIFICATioNS NEAT CEMENT. 1 SACK PER 5 TO 10 GALLONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSUREGROUT To depth offeet below sudace <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED El AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP El3 feet below surface or feet below su oe if>3 fee <br /> D t <br /> COMMENTSb 14 "r, perW 46 5 y M 10 0--01-0v- e� Qt!Q comlSw/nq µl <br /> 1llereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> / San Jo n County Ordinance Codes and Standards, and all other applicable California laws.CCrC•��, �.,r <br /> Signed / / Title/Company wpw 71.5T MO C IA-Ms- <br /> Print Name &ft492 - J4 OAA/ Date Of]Z f q <br /> EPA T ENT USE ONLY 7 7 Q <br /> Application Accepted By: Date Issued: 41 /� / <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information .' �r <br /> FA Name NAB+e4"fiwnlc Sealer P� AAddress S� qM� FA# �31 -0 P'R# <br /> FA PE S VIP Reviewed By ryj I <br /> Work Plan Date <br /> ❑G-57 -57AuftftalbnforOff rlo Sign Pemit ❑Workerscomp ❑WurkersCompWahar <br /> f � ❑Encmachmenler ❑ ccsAm i!5❑j.' WgApproval ❑MFRn tLCOMMENTSICONDITONS: w A l*�s fig . / I /y� / �y_ L I <br /> 6A L t"' ( c N VJ' iF1 d 0 OL'tPapule-4J.-d t TIK .�' IMF cc <br /> WP TYPE 1 PE SC FEE INFO AMT REMITTED CH C # RECV'D B �YDATE WELLLLIPERpMIT# INVOICE# Sd� <br /> Permit Z9 0' 1 $152x <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 <br /> ` IT 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com (S rtt <br /> EHD 29-0108-01-17 � r�3 Site MNgation Well Permit Application ie� a tq, <br /> Vh� VVV W +�r(^�-.e <br />