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a <br /> ,.tom:• \t I' jx Jf `' ')kpSAN JOAQUIN COUNTY RECEIVED <br /> ? �,5 ENVIRONMENTAL HEALTH DEPARTMENT SUN 20 <br /> c 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.conPERMITISERVICES <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION ^ <br /> For Wells and Borings Used for Contaminant Investigations and Remediation N <br /> twy NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J%� <br /> ^H4� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> �J e This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> V'��p� Job Address 200 N Wagner Ave cltyistatelzlp Stockton, CA, 95725 Phone <br /> Cross street VVashFngtnn APN 143-31-n7 95215' <br /> Property Owner' SPXCorporation 5"4m. l4o(Jrn}t, LLL <br /> Phone 980-474-3643 <br /> Address 13320-A Ballantyne Corporate Place 7-yo/tw/Z9 5&y/Srate1zlp Charlotte, NC 28277 <br /> C-57 Contractor Gregg Drilling Ovtr Ky I License# 485165 <br /> Phone 925-313-5800 <br /> Address 950 Howe Rd city/state/Zip Martinez, CA 94553 <br /> Consultant/Sub-Contractor Dudek License# Phone 76D-079-4128 <br /> Address gD5 3rd CtrPPt citylstate2lp Encinitas, CA 99094 <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offshe BodngsNVells Require Access Agreements or Encroachment Perils <br /> TYPE OF WELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Od MONITORING _20 HOLLOW STEM BORING DEPTH 80, 165 (Z BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 7 7/8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS 2" TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/ CONDUCTOR CASING ❑Yes ®No Baring Dia: Casing Ole: Casing Depth: <br /> ❑ INJECTION INr so,,,omnel ❑ HAND AUGER GROUT SEAL DEPTH 40 140 ft TREMIE TYPE TO BE USED: ❑AUGERS [3 HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefal Depth Is 30 Fq <br /> WELU SOIL BORING IDs MW-402, MW-451 GROUT SPECIFICATIONS Bentonite Neat Cement Grout with 3%to 5% Bentonite <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THATAPPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSUREGROUT To depth offeet below surface <br /> GROUT SPECIFICATIONS [j EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface#>3 feet <br /> COMMENTS: <br /> I hereby care"that I m authorized to complete this application and that the work will be done in accordance with <br /> j •r Joaq - County Ordinance Codes and Standards,and all other1 applicable California laws. } <br /> Signed---Z,/ <br /> igned Title/Comp/any GMi•lawi ��`. C � 4s� <br /> Print Name V Date 6— <br /> /J/J DEPARTMENT USE ONLY / J <br /> Application Accepted By: l/�j�f �e� j/�z Date Issued: 61.4,4 /�Z _ <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> F ili /Site Information <br /> FA Name FA Address FA# O D 2 Z PR# <br /> FA PE WP 'awed BY I A1,01lI­ Work Plan Date <br /> ❑C-57 -57 Authodzadon for Other to Sign Peng orke's Camp ❑Worker's Comp Waiver ❑EncroachmentPamA ❑A¢ Agreement 03fead Agency Appmv <br /> COMMENTS/CONDITIONS: 4ejj ,qya,{'mvJ-y EC bl"41-cr Av be. `K &-xAe� w/14 ge k"B1l V4v/f- <br /> SR TYPE PE SC FEE INFO JAMT REMITTED CHECK#I RECV-D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 2913 s73 59n, ;Ig 3z S'fZ X751,35 <br /> Peril 29,0f •3/3 130x 36g3Z _59Dm75-1 a <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />