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I �•,, SAN OAQUIN Environmental Health Department —COUNTY— Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 4t6g' ` d 41;�36 Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 131 East Harding Way City/State/Zip Stockton, CA 95204 Phone Cross Street N El Dorado Street APN 127-080-17 Property Owner, Ronald Ryo Yamada Phone Address 9411 Buffalo Ave City/Stale/Zip Oranclevale, CA 95662 C-57 Contractor Cascade Drilling, LP License# 1058336 Phone 916-638-1169 Address 3000 Duluth St Clty/Statelzip West Sacramento, CA 95691 ConsullanUSub-Contractor GHD Services, Inc. License# 17-00062639 Phone 530-558-1921 Address 4080 Plaza Goldorado Circle, Suite B City/State/Zip Cameron Park, CA 95682 CONSTRUCTION WORK TO BE PERFORMED: `Note: Dffsile Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING _(a HOLLOW STEM BORING DEPTH 68 fbo IRBOLTEDTRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporAValer) ❑ 14AMMEPJDRIVEN DIA.OF BOREHOLE 8inehes ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2inChes ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS Schedule 40 TYPE OF CASING: ❑STEEL I$PVC ❑ OTHER ❑ SOILBOWNG ❑ PUSH POINT(GP/CPT) CONDUCTORCASING [I Yes ($No Boring Dia: Casing Ole: Casing Depth: ❑ INJECTION(AF soaoe 0zmel ❑ HAND AUGER GROUT SEAL DEPTH 49 flag THERE TYPE TO BE USED: CRAUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes tallo (Note:Maximum Freefall Depth is 30 Fq WELLJSOIL BORING IDS MW-24 GROUT SPECIFICATIONS Portland Type I/Il Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLY) If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL 10s ❑PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE [:]PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �� ^ �' San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /� gQ2t Title/Company Staff Geologist GHD Services, Inc. Print Name Ryan Bast Date 09/23/2019 EPARTMENT USE ONLY Application Accepted By: ! Date Issued: Z� I Grout Inspection By/Dates: Destruction Inspection By/Dates: —0 Faciiil /Site Information FA Name wwr aoos— NC. 4" FAAddress I5OZ, u Q," FA# OQ Z90 �� PR# 10540300 FA PE WP Reviewed By �•�r� Work Plan Date 11 13chop 0C-57 G57 Authorization for Other to Sign Permit ❑Wakens Comp ❑Workers Comp Walver ❑Encroachment Permit ❑AaessAgmement ❑Lead Agency Approval/ ❑MMFR COMMENTS/ ONDITIONS I_ � /i trend D• ,4PIn r5 IIl4 'IM `�t� d s !/��pw(•7 J� jyl WP TYPE I PE I SC FEE INFO JANIT R ITTEDI CHEECKK# REECCV'D BY DATE WELL/PfE^RMIT# '7 INVOICE# Permit 290 ( 33 s152x � J.y0S30 U IQ I OQ`N 22-3 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0708-01-17 S Siloih^galion;elLpermil Appliwlpn