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1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVpIERROmNiMpsE ENTRAL H <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjcehd.com VICE <br />HEALTH <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 />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />RECEiVag, <br />MAY 1 8 201? <br />310 i. W -/-rij <br />C-57 Contractor 6, „ode zp <br />Address QQ C) Pi v t 6 6' Tire <br />W /ye Consultant/Sub-Contractor j <br />Address /6" 0Coriar cdr &Te /01 <br />Address <br />LP. <br />Date Issued: <br />5 DP 7 r -rut- <br />7 <br /> <br />. 0 P pp-4 6 /141 1)7 <br />Application Accepted By: <br />Grout Inspection By/Dates: DP- (4 <br />Destruction Inspection By/Dates: <br />Cross Street 6Gfr /6'k' A ve•nue <br />Foy Wcct Ch ti(ch re'e City/State/Zip hone 2.0q <br />APN /523 00 <br />Phone 790 —359 <br />City/State/Zip <br />License# 93SPO Phone <br />City/State/Zip Wect rcve1t.47-0) GA 9,z f/ <br />LIcense# 67 7 Jo Phone Q -.7-7 93-3Y1) <br />City/State/Zip Pe 7-0/00940 1 9i/sy-- <br />Job Address <br />Property Owner* <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Waler) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Sparge, Ozonel <br />OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br />HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> o MUD ROTARY <br />)51" PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br /> El OTHER: <br />OP-5 T hrovih O12-12, <br />CONSTRUCTION SPECI5ICATIONS_ ,./ <br />BORING DEPTH Li e 10, LI --O 6;f2 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />CIA. OF BOREHOLE ) ,/,/ 7, 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Z, I/ Casing Die: ---- Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? atYes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED <br /> p OVER-BORE DIAMETER of Inches to depth of feet <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface If >3 feet <br />COMMENTS: <br />that I am authorized to complete this <br />dac(iiid eiichtY socid4r4e nd oAket#iii <br />R,PliC040)1. 1I that.the- work 4I1I.bedotrA do amid- <br />Signed Title/Company Regional Director / Cascade Drilling, <br />Print Name Ralph McGahey Date 05/16/2017 <br /> <br />DEPARTMENT USE ONLY <br />TREMIE TYPE TO BE USED 0 AUGERS El HOSE 0 PIPE <br />herebrOrti, <br />0,214 <br />Facility/Site Information <br />FA Name <br />FA PE <br />0 0-57 0 C-57 Authorization for Other to Sign Permit 0/Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit El Access Agreement Ei Lead Agency Approval GaliIFR <br />44 47' (44.•—• 6 0,4_0 <br />2-4?6D WP Reviewed By <br />FA Address 5(00 C4 ck <br />114A-- <br />FA# 0O2-3z-‘0 <br />Work Plan Date <br />PR# <br />COMMENTS/CONDITIONS: ,-s ° <br />4t.bL /4.J - <br />SR TYPE FEE INFO AMT REMITTED "CHEPK#- -12EGy'D BY DATE _ , SERVICE REQUEST* NVOICE# <br />si co 77-CI S/ <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application