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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c,•.-�'' �;cP Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com <br /> �IFOR� <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 /> 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 701 East Charter Way City/State/ZipStockton, CA, 95206 Phone 209-467-0305 <br /> Cross Street Stanislaus Street APN 147-343-11 <br /> Property Owner* Swaran Chouhan Phone 209-467-0305 <br /> Address 1632 Paola Place City/State/Zip Manteca, CA, 95337 <br /> C-57 Contractor All Well Abandonment License# 848359 Phone 916-363-9355 <br /> Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova, CA, 95742 <br /> Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 <br /> Address 837 Shaw Road City/Statelzip Stockton, CA, 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA OF BOREHOLE O MULTIPLE CASINGS O MULTILEVEL WELL CASING DIA <br /> O SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [I PVC❑OTHER <br /> O SOIL BORING O PUSH POINT(GPI CPT) CONDUCTOR CASING O Yes O No Boring Dia Casing Dia Casing Depth: <br /> ❑ INJECTION wrsaarge.O:onel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS [IHOSE EIPIPE <br /> O OTHER O OTHER GROUT SEAL PUMPED? O Yes O No (Note:Maximum Freefali Depth is 30 FI) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 10 ®OVER-BORE DIAMETER of s an "inches to depth of max 6s feet <br /> WELI_100w-1, MW-2, 14W-3, rrx-'• vcr-", vw-z, VW-3, VW-4, Err-" and EW-2 ❑PRESSUREGROUf Todepthof feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE p PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: See work plan for additional details; <br /> hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br /> San Joa uin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Project Geologist/AGE <br /> Print Name Da el Vil nueva <br /> aDate 10/27/2015 <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByZ//T7�/�t1���Z Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address I FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑G57 O G5/AutW7ation for Other to Sign Pemrit O Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit O Access Agreement O Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan5Z?j �`�� %2 /�., t w�,(' 1,121-/j S FC1035,55 <br /> Permit 2)0 3t-j $130x c� -J,7fl 736;0& <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />