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CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Re Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING <br />ID MONITORING <br />0 EXTRACTION (Vapor/Water) <br />0 SOIL VAPOR PROBE <br />1:1 SOIL BORING <br />0 INJECTION (Air Spam Ozone <br />El OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br /> El HOLLOW STEM <br /> El HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> El PUSH POINT (GP/ CPT) <br /> El HAND AUGER <br />0 OTHER: <br />CONSTRUCTION SPECIF1 <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS, <br />CONDUCTOR CASIN <br />GROUT SEAL DEPTH <br />GROUT SEAL P MPE <br />GROUT SPP ICA <br />Ed TRAFFIC BOX 0 STOVE PIPE <br />LTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />OF CASING: 0 STEEL 0 PVC El OTHER <br />Bo ng Die: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS El HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />ATIONS <br />NS <br />DESTRUCTION WORK TO BE PERFORM <br /># WELLS TO BE DESTROYED 3 <br />WELL IDs SW-101, MW-6, and MW-106 <br />UCTION METHOD: (CHECK ALL THAT APPLY1 <br />R-BORE DIAMETER of ** inches to depth of ** feet <br />PRESSURE GROUT To depth of ** feet below surface <br />GROUT SPECIFICATIONS Neat cement containin. <4% bento <br />0 HOSE 0 PIPE AUGERS <br />COMMENTS: <br />TREMIE TYPE TO BE USED 0 <br /> EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />See attached table for well constru6tiort-details for the information marked " ** " <br />SAN JOAOL.01 <br />COUNTY <br />rItness grows heir <br />Environmei..al Health Department <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 1739W. Durham Ferry Rd. AKA 31448 Highway 33 City/State/Zip Tracy, CA 95304 Phone 209-522-4119 <br />Cross Street Highway 331 Durham Ferry Road APN 255-310-023 <br />Property Owner* Seeds of LifeNerbum Dei / Ellen Hess \.ione 415-533-0322 <br />Address 3365 19th Street City/State/Zip San Franci o, CA 94110.41 <br />C-57 Contractor V&W Drilling License# 720904 <br />City/State/Zip Galt, Cka <br />hone 209-469-7700 <br />Address 1133 Blackhurst <br /> <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. License# 5023, <br />Phone 209-522-4119 <br />Address 1172 Kansas Avenue City/State/Zip Modesto, CA t58-61 <br />Signed <br />I here y certify that I a aut <br />San Joaq <br />Print NameGregory Stahl <br />6 ized to complete this application and that the work will be done in accordance with <br />inance Codes and Standards, and all other applicable California laws. <br />Title/Compan VP / round Zero Analysis, Inc. <br />Date S2: 2\- r <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 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 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit lifcess Agreement Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit Lai oZ___ $152 x <br />4--; <br />' 1/ tcr7 <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