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P urN�, <br /> °? � c02 SARxJ0A0uiN EnvironmerllLal Health Department <br /> COUNTY <br /> e' FZ0 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 <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 14700 Schulte Road city/State/Zip Tracy, CA 95377 Phone (209)836-8269 <br /> Cross Street S. Lammers Road APN 209-240-024 <br /> Property Owner" Owens-Brockway Glass Container, Inc. Phone (209)836-8269 <br /> Address 14700 Schulte Road City/State/Zip 95377 <br /> C-57 Contractor Cascade Drilling License# 1058336 Phone 916 638 1169 <br /> Address 3000 Duluth Street City/State/Zip West Sacramento,CA 95691 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [X MONITORING -IN HOLLOW STEM BORING DEPTH 85 feet [XBOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 12-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 4-inch <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SChed 40 TYPE OF CASING: ❑STEEL [X PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes I$No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 58 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [$PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [X Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs MW-4R GROUT SPECIFICATIONS St,3ndard 15 sqck coix with no more than 4% bentonite <br /> t ( ko ,C a—J1 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ' <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑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 if>3 feet <br /> COMMENTS: <br /> h re 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 CKG Environmental, Inc. <br /> Print Name Chri Ina Kennedy Date 6/2/2020 <br /> EPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: �j /2 ��710 2� <br /> Grout Inspection By/Dates: ` <br /> Destruction Inspection By/Dates: <br /> Facilit /Si a Information / <br /> FA Name tf&iVl 1MGW FA Address ( L f �0 3G `���� FA# O Z� 6) PR# p�(� 9 <br /> FA PE WP Reviewed By r` Work Plan Datef�C <br /> ❑C-57 G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑A�ccees-s-Agreement ❑Lead Agency Approval ElMFR <br /> COMMENTS/CONDITIONS: �!K/_ ► ry p**�i -ry �HD W 1 -Y., �' 4 cwt F-s-r- <br /> ( Wal S.cetjands 1� 1 � . q .. -t <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D B DATE , f }SWELL PERMIT# INVOICE# <br /> Permit 01 313 $152 x l S2 p to W i o D `a0 -`2� <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 29-01 08-01-17 Site Mitigation Well Permit Application <br />