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PpUTA� <br /> S A N J 0 A Q u I N Environmental Health Department <br /> COUNTY- <br /> °9cr�aR P Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION NOV 0 9 2017, <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> 169-163-01 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct andror instal I 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 2222 S. Airport Way City/State/Zip Stockton, CA, 95202 Phone <br /> Cross Street E 8th Street APN 10 i0-5 `01 <br /> Property Owner* City of Stockton Phone 209-937-8309 <br /> Address 425 N EI Dorado Street city/state/zip Stockton, CA, 95202 <br /> C-57 Contractor V&W Drilling, Inc. License# C57-720904 Phone 209-469-7700 <br /> Address 3806 Duck Creek Drive City/State/Zip Stockton, CA 95215 <br /> Consultant/Sub-Contractor Condor Earth License# John Lane, PG 6795 Phone 209-234-0518 <br /> Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA, 95206 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/VVels Require Access Agreements or Encroachment Permits <br /> TYPE OF WEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONS TOR NG 2- 0 HOLLOW STEM BORING DEPTH -40 feet O BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapodWata) O HAMMER/DRIVEN DIA OFBOREHOLE g OMULTIPLE CASINGS OMULTI LEVEL WELL CASING DIA <br /> O SOIL VAPOR PROBE ❑ MUD ROTARY CASING TH CKNESS 'J O TYPE OF CASING O STEEL 19 P\C O OTHER <br /> ❑ SOIL BOR NG ❑ PUSH POINT(GPI CPT) CONDUCTOR CAB NG ❑Yes &No Boring Dia Casing O a Casing Depth: <br /> O INJECTI ON(Air Soaree.Ozone l O HAND AUGER GROUT SEAL DEPTH —7-3' TREMETYPETOBEUSED. ❑ANGERS OHOSE ❑PIPE <br /> O OTHER O OTHER: —GROUT SEAL PUMPED? []Yes fifto (Not:Maximum Free fAI Depth is 30 F) <br /> WELLISOILBORNGDs -rW-1 to AgL-J-2 GROUTSPEORCATIONS NeA-k c_B4� ovt' klop(vwfeOt Be.v a-'. <br /> DESTRUCTION WORK TO BE PERFORMED DESTRUCTION METHOD:(CHECKALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSUREGROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPETO 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 1 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 applicableCPlffomla laws. <br /> Signed TitleJCompany 106C <br /> Print Name �Ci-�^>°� Date ill 9 I 2-0/-?- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: d-6 /1 -3 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection BVDates7 <br /> FaclAWShe Information <br /> FA Named, rl FA Address `LZZZ f (f' FA# �r'?j PR# 77 22/r <br /> Z <br /> FA PE Z WP Reviewed By Work Plan Date 1() '� 17 <br /> 657 ❑G57 Authorization for Other to Sign Permit arMes Comp ❑Worker's Comp Waiver ❑Encroachment Permit O Access Agreement ❑Lead Agency Approval FR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE �7��yPE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit �/ul 3i3 $152x '7._ 3 /-<-" 1{ ,I - 3-7-9-7 <br /> /yt 868 E. Hazelton Avenue I Stockton, Californiy�95205 1 T 209 468-3420 209 464-0138 www.sjcehd.com <br /> ���£HD 29-014-01-17 ,J /! r[. Ste Mbgabon Wal Pemil Appicabon <br />