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, <br />COUNTY— <br />rn Greatness grows here. <br />• <br />'on • sAN joAn, • tj N <br />hone 209-942-6018 <br />APN Cal Trans Right of Way <br />City/State/Zip Stockton, CA 95205 <br />Cross Street Highway 33 <br />St of Cal Department of Transportation — Paul <br />Property Owner* Cavanaugh <br />Address 1976 E. Dr. Martin Luther King Jr., Blvd <br />City/State/Zip Galt, CA 9 Address 1133 Blackhurst <br />N METHOD: CHECK ALL THAT APPLY ESTRU <br />Print NameGregory Stahl <br />Signed <br />San Joaq Ord* ance Codes and Standards, and all other applicable California laws. <br />Title/Company VP / Ground Zero Analysis, Inc. <br />Date 9/13/2017 <br />C-57 Contractor V&W Drilling License# 720904 Phone 209-469-7700 <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />Address 1172 Kansas Avenue <br />License# 5023 <br />City/State/Zi . M <br />Phone 209-522-4119 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require ents or Encroachment Permits <br />TYPE OF WELL/BORING <br />ID MONITORING <br />CI EXTRACTION (Vapor/Water) <br />El SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Soaroe. Ozonel <br />OTHER <br />WELL/ SOIL BORING IDs <br />0 PUSH POINT (GP/ CPT) CONDUCTOR CASING <br />0 HAND AUGER GROUT SEAL DEPTH <br />CI OTHER: GROUT SEAL PUMPED? <br />&Row- SPECIFICATIONS <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATION <br /> El HOLLOW STEM BORING DEPTH <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE <br />CI MUD ROTARY CASING THICKNESS <br />BOLTED TRAFFIC BOX 1:1 STOVE PIPE <br />E CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING: 0 STEEL 0 PVC 0 OTHER <br />No Bonng Di Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />Note: Maximum Freef all Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br />It WELLS TO BE DESTROYED 1 <br />WELL IDs MW-4 <br />GROUT SPECIFICATIONS Neat cement containing <4% be tonite <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />I hereby certify that I a,t autho ed t complete di' application and that the work will be done in accordance with <br />RE <br />SURE GROUT <br />OSIVES <br />USHROOM CAP <br />DIAMETER of 10 inches to depth of 22 feet <br />To depth of feet below surface <br />From to feet below surface <br />0 3 feet below surface or feet below surface if >3 feet <br />OVER- <br />0 PR <br />COMMENTS: See attached table for well constru 'on details for some of the above information. <br />Environme ii Health Dyertment <br />CCEIvp" <br />SEp r 44,0sa <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIOR j 2017 <br />For Wells and Borings Used for Contaminant Investigations and Remediatip °AliN/7-A <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ir/SEVIEALrH <br />v iCEs 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 />140 Ft SE from Corner of HWY 33 & Durham Ferry Road <br />Job Address Intersecton <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <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 1:1 Worker's Comp CI Worker's Comp Waiver 0 Encroachment Permit 1:1 Access Agreement ID Lead Agency Approval ID MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $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 <br />City/State/Zip Tracy, CA one 09-942-6018 <br />