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SA N J O A Q U I N Environmental Health Department COUNTY SITE MITIGATION WELL & 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 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address R1 R S. Stanislaus Street City/State/Zip Stockton,CA 95206 Phone NA Cross Street E. Taylor Street APN 147-294-120 Property Owner* George Baker Phone Address 4568 Feather River Drive, Suite A City/State/Zip Stockton, CA, 95219 C-57 Contractor Gencon Consultants, Inc.. License# 716050 zky 4�f: 7- 1 Phone 91 F-R52-91 1 R Address 3160 Gold Valley Drive,Suite 800 City/state/Zip Rancho Cordova CA 95742 Cons ultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsMlells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH varied: 7 ft max❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2 SOIL VAPOR PROBE �_❑ MUD ROTARY CASING THICKNESS 0.25 in TYPE OF CASING: ❑STEEL ❑PVC Rl OTHER Nylaflow whing ® SOIL BORING 6 ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soame.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Fre all Depth Is 3 Ft) WELL/SOIL BORING Ds Vapor Probes:SV 1 through SV5 GROUT SPECIFICATIONS hit V447ojr 69 f 11 1 r'e�-! Soil Rnrings:CTSI through GS6 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: IV I through sys will be temporary probes and will be destroyed upon vapor sample collection..AJI tubing will be pulled by hand,and the boreholes will be over-drilled to remove all sand and bentonite.Following over-drilling activities,the boreholes will be grouted with neat cement via freefall methods,and capped with concrete or soil to match the surrounding surface. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with n,Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Construction Manager/Geocon Print Name Bob Kimball Date 3-y-�-Z"f� V� DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: v' —' U Facility/Site Information FA Name , FA Address S, S u FA# V ' PR# 5 A 13 FA PE 2f q � WP Reviewed By w Work Plan Date L �� v ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Camp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: >µb�r' f�® vj"-V., >f . ks-w� f 0,10 WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit l $152x �7 l/� 3 V�{V#Td bL 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 OS-01-17 kSl��gation Well Permit Application 4Z,=1 a