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Pauin,. <br /> SAN JOA U N Environmental Health Department <br /> COUNTY <br /> Greatness grows here <br /> Gp3ECC OMIED <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation NOV 0 9 2017 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> �NVIRONMENTHEAIftf <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 /> .lob Address : Z-2-" _S.Airport Way City/State/Zip Stockton, CA, 95202 Phone <br /> Cross Street E 9th Street APN 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/VVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH -5 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor(Water) ❑ HAMMER(DRIVEN DIA OF BOREHOLE 2.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _ <br /> 9 SOIL VAPOR PROBE IL ❑ MUD ROTARY CASING TH:CKNESS_jZ0,v E _TYPE OF CASING: ❑STEEL 1 PVC ❑ OTHER <br /> ❑ SOIL BORING PUSH POINT(GP CPT) CONDUCTOR CASING ❑Yes P No Boring Dia Casing Dia: Casing Depth <br /> ❑ INJECTION(Nr Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH V 31 TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes Q No (Note Maximum Freefall Depth is 30 Ft) <br /> WELL SOIL FOR NG IDs GROUT SPECIFICAT ONS <br /> SVf - S V – 4 <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 /> t� 5VP, - <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> S Joaquin County Ordinance Codes and Standards,and all other applicable7,J <br /> rnia laws. <br /> Signed � �' _ Title/Company N & c�Z 0-,/ <br /> Print Name ,JJ� t ^�— Date_ _!!1712-01 <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 /f �, _/` - FA Address 's N �, FA# 5 PR# <br /> FA PE �+�� WP Reviewed By Work Plan Date <br /> ❑C-57 ❑G57 Authorization for Other to Sign Permit Q(Workers Comp ❑Worker's Comp Waiver ❑Ericmachmenl Permit ❑Access Agreement ❑Lead Age y Approval R <br /> COMM ENTS/CONDITIONffS: j" 011k+ '_ _ V% <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATEWELL PERMIT# INVOICE# <br /> Penult ?j i $152 x lJl f �j 7 S-7 7 <br /> 1868 E Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 of209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 0"1-17 Site Mitigation Wed Permit App icat,on <br />