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I hereby certify that am aut orized to A l <br />San Jo?qui i Co t ma <br />Print NameGregory Stahl <br />Signed <br />SAN IOWA Environmei.cil Health Department <br />COUNTY <br />Greatness grows herr <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 woreed. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Jo q 'n County Well Standards. <br />Job Address -88 FT East on Durham Ferry Road at the HWY 33 Intersection City/State/Zip Tracy, CA Phone 209-468-3000 <br />Cross Street Highway 33 <br />Property Owner* San Joaquin County Dept of Public Works <br /> <br />APN County Right of Wa d, <br /> <br />Phone 209-468-3000 <br /> <br />Address 1810 E Hazelton Avenue City/State/Zip Stockton 5205 <br />C-57 Contractor V&W Drilling License# 720904 Phone 209-469-7700 <br />Address 1133 Blackhurst City/State/Zip t, C 956 <br /> <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. License# 5023 Phone 209-522-4119 <br />Address 1172 Kansas Avenue City/State/Zi de v A 95351 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Req Acces greements or Encroachment Permits <br />INSTALLATION TYPE CONSTRUCTION SPECIFICA <br />HOLLOW STEM BORING DEPTH <br />HAMMER/DRIVEN DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />GROUT EAL PUMP <br />GFIO T SPECIFIC <br />TYPE OF WELL/BORING NUMBER <br />MONITORING 0 <br />EXTRACTION (Vapor/Water) 0 <br />ID SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparse, Ozonel 0 HAND AUGER <br />OTHER 0 OTHER: <br />WELL/SOIL BORING IDs <br />ION <br />TED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL ID PVC 0 OTHER <br />No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: ci AUGERS 0 HOSE 0 PIPE <br />o (Note: Maximum Freef all Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 1 <br />WELL IDs OW-1 <br />GROUT SPECIFICATIONS Neat cement containing <4% bentonite <br />IRENE TYPE TO BE USED El AUGERS CI HOSE CE PIPE <br />DESTIVC ION METHOD: (CHECK ALL THAT APPLY) <br />OAR-BORE DIAMETER of 10 inches to depth of 25 feet <br />ESSURE GROUT To depth of feet below surface <br />XPLOSIVES From to feet below surface <br />MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: See attached table for well construct on det Is for some of the above information. <br />mplete this application and that the work will be done in accordance with <br />ce Codes and Standards, and all other applicable California laws. <br /> Title/Company VP / Grund Zero Analysis, Inc. <br />Date Sr r7 <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 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access 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 $152x I <br />1868 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