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1-114 COUNTY <br />tn ,cc grows hprp <br />Environmek..al Health Department SAN JOAOLA <br />Phone 209-469-7700 License# 720904(, , <br />APN 255-310-024 <br />City/State/Zip TracyQd 953o' \. <br />Phone 209-522-4119 <br />Address 1133 Blackhurst <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />City/Statei? Galt, C <br />License# 523 Phone 209-522-4119 <br />563 <br />Address 1172 Kansas Avenue <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells <br />p esto, CA 95351 <br />Is Agreements or Encroachment Permits <br />City/S <br />TYPE OF WELL/BORING NUMBER <br />12 MONITORING <br />EXTRACTION (Vapor/Water) 0 <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Spam, Ozonel 0 HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs <br />ICAT <br />OLTED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />No Boring Die: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />TION <br />INSTALLATION TYPE CONSTRUCTION SPECI <br />HOLLOW STEM BORING DEPTH <br />HAMMER/DRIVEN DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />GRO T AL PUMP <br />G 0 SPECIFI <br />DESTRUCTION WORK TO BE PERFORIVIED: <br /># WELLS TO BE DESTROYED 2 <br />WELL IDs MW-7 and MW-107 <br />GROUT SPECIFICATIONS Neat cement containing <4%entonite <br />TREMIE TYPE TO BE USED El AUGERS El HOSE El PIPE <br />STRUCTION METHOD: CHECK ALL THAT APPLY <br />PRESSURE GROUT <br />EXPLOSIVES <br />El MUSHROOM CAP <br />VER-BORE DIAMETER of ** inches to depth of ** feet <br />To depth of ** feet below surface <br />From to feet below surface <br />3 feet below surface or feet below surface if >3 feet <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 />/.\ City/State/Zip Tracy, CA 95304 \ Phone 209-522-4119 <br />Property Owner* Jose and Delia Camacho <br />Address 1697W. Durham Ferry Rd. <br />C-57 Contractor V&W Drilling <br />Job Address 1697 W. Durham Ferry Rd. <br />Cross Street Highway 33 <br />COMMENTS: ** See attached table for well ccMstructiqh details for information marked " ** " <br />I hereby certify that I am authAdrized to complete this application and that the work will be done in accordance with <br />San Joa Co dinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print NameGregory Stahl <br />Title/Compan <br />Date <br />VP/Ground Zero Analysis, Inc. <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />12 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit liKcess Agreement 0 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 Zgo Z., $152x <br />1868 E. Hazelton Avenue I 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