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Q <br /> SAN J 0 AQ u i N Environmental Health Department <br /> COUNTY <br /> - Greatness grows here <br /> REMOVED <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION NOV 0 9 2017 <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEAL <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 ' Z2-Y�f S.Airport Way City/State/Zip Stockton, CA, 95202 Phone <br /> Cross street E 9th Street APN (try _ 15-t-0 I <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 BodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WEL BLI ORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 2 ® HOLLOW STEM BORING DEPTH –40 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CAS'NG DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS f fr TYPE OF CASING- ❑STEEL 19 PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes IB'No Boring Dia Casing Dia: Casing Depth <br /> ❑ INJECTION IAMSoarae.Ozanel ❑ HAND AUGER GROUT SEAL DEPTH —7-3' f TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ G4 Yes No (Note:Maximum Freefall Depth Is 30 Ft) <br /> WELL SOIL BORING IDs -i' VJ;3 to M w–'iyi- GROUT SPECIFICATIONS /Veale c� -mow L j40L*vL*e4 8 eytow-Ve­ <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 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 applicable Iifomia laws. <br /> Signed '{'t- TiUe/Company PCc (0 q2 <br /> Print Name ��`� �L' �� Date 110 !-:�- <br /> -� DEPARTMENT USE ONLY � � / /�} �'7 <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Nameeilt- FA Address FA# o . PR#¢ � s <br /> FA PE WP 14 <br /> Re iewed By Work Plan Date z7 / '7 <br /> G57 ❑G57 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval R <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PEYy SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE , �pWELL PERMIT# / INVOICE# <br /> Permit D' /1 $152 x 1j ��-(� S ( W f L `7S 76 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 209 464-0138 1 www.sjcehd.com <br /> EHD 2"1 08-01-17 S.le Mitigation Well Permt Application <br />