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GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS Gi HOSE ID PIPE <br />Inkier Date 2/21/17 Print Name John <br />I hereb if, that I am authorized to complete this application and that the work will be done in accordance with <br />oaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Project Geologist Fulcrum Signed <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />O OVER-BORE <br />El PRESSURE GROUT <br />El EXPLOSIVES <br />['MUSHROOM CAP <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />Application Accepted By: <br />Grout Inspection By/Dates: -- <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />RECEIVED <br />FEB 23 , <br />ENVIRONMENTAL HEALTH <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 P ERMIT/SERVICES <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <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 />Job Address 18 E. 11th Street City/State/Zip Tracy, CA 95376 Phone NA <br /> <br />Cross Street N. Central Ave APN 235-171-03 <br /> <br />Property Owner* Nathaniel Papadakis <br /> <br />Phone 206-7794877 <br />Address 2502 27th Ave W . Seattle WA 98199 City/State/Zip <br /> <br />C-57 contractor Gregg Drilling Co <br />License# 087 485168 <br /> <br />Phone <br />4 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Address 950 Howe Road <br />Consultant/Sub-Contractor Fulcrum Resources/John VVinkler Phone 800-385-7105 License# CA PG # 7456 <br />a. M rtinez, GA 94553 City/State/Zip <br />Address 517 S Ivy Ave City/State/Zip Monrovia, CA 91016 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> <br />TYPE OF WELL/BORING <br />D MONITORING <br />El EXTRACTION (Vapor/Water) <br />M SOIL VAPOR PROBE <br />CI SOIL BORING <br />ID INJECTION (Air Some, Ozone( <br />ID OTHER <br />WELL/SOIL BORING IDs S B1 <br />NUMBER INSTALLATION TYPE <br /> El HOLLOW STEM <br />0 HAMMER/DRIVEN <br />—4— 0 MUD ROTARY <br /> OA PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br /> 0 OTHER: <br />SB2, SB3, SB4 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 15 FT 1:1 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 2 INCH CI MULTIPLE CASINGS CI MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: CI STEEL CI PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 1:1 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 1:1 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DEPARTMENT USE ONLY <br />Date Issued: <br />Sir 0_1 -I <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Workers Comp Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR ,EI <br />COMMENTS/CONDITIONS: --. /-1XLIA ,-, . -. , c,,v-- •‘//7/ 7 .c...r ,.).•,,t...1),,si , / , 4-N.4_,k1).-1-- • <br />SR T1PE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permitz9 0 L.--;" 31 3 e-. <br />$139 x :"2,,, <br />'''- / .7 i ,i1,- I,' Lr/sli? A.--Ce .7 7/ <br />4// 7 1,7'7."4/ <br /> cL2 76'776 <br />EHD 29-01 10-26-2015 <br /> <br />Site Mitigation Well Permit Application