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or- co, o • <br />1 <br />Consultant/Sub-Contractor Condor Earth License# <br /> <br />Phone (209) 234-0518 <br /> <br />Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA 95206 <br /> <br />SAN JOAQUIN <br /> <br />Environmental Health Department <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 /> <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 V&W Drilling, Inc. License# C57-720904 Phone (209) 469-7700 <br /> <br />Address 1133 Blackhurst Drive City/State/Zip Galt, CA 95632 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />MONITORING (g) <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE 0 <br />Egi SOIL BORING 1 <br />INJECTION (Air Surge. Ozonel 0 <br />OTHER <br />WELU SOIL BORING IDs SB-4 <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 10' <br />HAMMER/DRIVEN DIA OF BOREHOLE 4-44411 <br />MUD ROTARY CASING THICKNESS <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING DI Yes 0 No <br />HAND AUGER GROUT SEAL DEPTH <br />OTHER: GROUT SEAL PUMPED? 0 Yes El No <br />GROUT SPECIFICATIONS Neat Cement <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: 8.25" Casing Dia: Casing Depth <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />(map attached) <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED <br /> <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS 1=I EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED 1=I AUGERS I=1 HOSE 0 PIPE <br /> CI MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: Soil boring SB-4 to depth of 10 feet, neat cement grout <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/Condor Earth <br />Print NameJohn P. Lane Date <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: ) <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name - 'rs ') '' .1 ‘1'(' (`-"-"\k-1 ''''"4{ FA Address tb--W E 11.0.-z.-t 44'4 6"-- FA# 002-13n PR# 0.5-v or i (e, <br />FA PE .-611C0 WP Reviewed By i- )( Work Plan Date v, / ci ) ---1 <br />0 C-57 D'6-57 Authorization for Other to Sign Permit 81.--Norker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement are'ad Agency Approval 1:21"1-FR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit,)(.14.,‘ 7>R, $152x t $ IS --1, 6)1 I- -Ni4 1 1- livi i i Ofew>"11.0(0- <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />Signed