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TA/ - or- 0 SAN JOAQUIN Environmental Health Department <br /> <br />-COUNTY <br />Greatness grows here. <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 />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 1810 E. Hazelton Avenue City/State/Zip Stockton, CA 95205 Phone (209) 468-3000 <br />Cross Street S. B Street APN 155-18-002 <br /> <br />Property Owner* San Joaquin County General Services Department Phone (209) 468-9598 <br />Address 44 N. San Joaquin Street, Suite 590 City/State/Zip Stockton, CA 95202 <br />C-57 Contractor California Push Technologies License# C57-884827 Phone (510) 357-3677 <br /> <br />Address 820 Aladdin Avenue City/State/Zip San Leandro, CA 94577 <br /> <br />Consultant/Sub-Contractor Condor Earth License# Phone (209) 234-0518 <br />Address 188 Frank West Circle, Suite f City/State/Zip Stockton, CA 95206 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLJBORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />21 SOIL BORING <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br />4 E1 PUSH POINT (GP/ CPT) <br />0 HAND AUGER <br /> 0 OTHER: <br />GW-1, GW-2 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 80-100 feet <br />DIA. OF BOREHOLE 1.5 inch <br />CASING THICKNESS <br />CONDUCTOR CASING ID Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes El No <br />GROUT SPECIFICATIONS Neat Cement <br />INJECTION (Air Suarue Ozone) <br />OTHER <br />WELU SOIL BORING IDs CPT-1, CPT-2 <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE LEI PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />LI OVER-BORE DIAMETER of inches to depth of feet <br /> <br />WELL IDs 1=1 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS 1=1 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED El AUGERS El HOSE 1:1 PIPE El MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: CPT-1 and CPT-2 borings to approximately 80-100, subject to interpretation of MiHPT results, two "hydropunch" borings GW-1 and <br />GW-2 to collect confirmation groundwater samples. <br />I hereby certify that I 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 California laws. <br />Title/Company PG #6795/1 ondor Earth <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: f II <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name cc,;/. ‘,„:,.., Lsi...-A-1 frNa4-%.‘ <br />fei.s..1 FA Address q10 il VkAtejci, A 4-44'-' FA# cv 253m PR# c2s-1/44,0 81,L <br />FA PE r3J% ki3O WP Reviewed By L. _y Work Plan Date (.0 / /Ai) -7 <br />1=1 C-57 EK57 Authorization for Other to Sign Permit LiK)rker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement lirread Agency Approval IIKFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit pvo C 12 \ -12 $152x 4 `-‘5-1/40 6 L. <br />1-t iall-i Vile031Vt( <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />Signed <br />Print NameJohn P. Lane Date