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SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> `c4��FoaNp/; Telephone:(209)468-3424 Fax:(209)468-3433 Web:vvvvw.slcehd.com <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 6484 N Waverly Rd. city/stateizip Linden,CA 95236 Phone 209-468-3066 <br /> Cross Street Floor Rd. APN 093-440-02 <br /> Property owner* San Joaquin County Public Works Dept.Solid Waste Phone 209-468-3066 <br /> Address 1810 East Hazelton Ave. city/statelzip Stockton,CA 95205 <br /> C-57 Contractor Yellow Jacket Drilling License# 643081 Phone (909)989-8563 <br /> Address 9460 Lucas Ranch Rd. city/state/zip Rancho Cucamonga,CA 91730 <br /> Consultant CB&1 License# Phone (619)279-4251 <br /> Address 1042 Willow Creek Road Suite A101,PMB 512 City/State0p Prescott,AZ 86301 <br /> CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BoringsiWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 261* ❑BOLTED TRAFFIC BOX ®STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) K) HAMMERIDRIVEN DIA.OF BOREHOLE 10" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ® SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS 2"Triple Nest TYPE OF CASING ❑STEEL®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth <br /> ❑ INJECTION(At Soaae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefell Depth is 30 Ft) <br /> WEWSOILBORINGIDs SG-10A GROUT SPECIFICATIONS Medium Bentonite Chips <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 /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company District Manager/Yellow Jacket Drilling <br /> Print Name Dean Coblish DateMarch 29,2016 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECWD BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit $130 x <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />