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SAN4JOAULA <br />COUNTY <br />i:igo x‘ Greatness grows here. <br />Environme I 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 1697W. Durham Ferry Rd. City/State/Zip Tracy, CA 95304 Phone 209-522-4119 <br />Cross Street Highway 33 APN 255-310-024 <br />Property Owner* Jose and Delia Camacho Phone 209-522-4119 <br />Address 1697 W. Durham Ferry Rd. City/State/Zip Tracy, CA 95304 <br />C-57 Contractor V&W Drilling License# 720904 Phone 209-469-7700 <br />Address 1133 Blackhurst <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />City/State/Zip Galt, CA 95632 <br />License# 5023 Phone 209-522-4119 <br />City/State/Zip Modesto, CA 95351 Address 1172 Kansas Avenue <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />MONITORING <br />EXTRACTION (Vapor/Water) CI <br />SOIL VAPOR PROBE 0 <br />SOIL BORING 0 <br />INJECTION (Air Spam, Ozonel 0 <br />OTHER El <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH <br />HAMMER/DRIVEN DIA. OF BOREHOLE <br />MUD ROTARY CASING THICKNESS <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING <br />HAND AUGER GROUT SEAL DEPTH <br />OTHER: <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: El STEEL 0 PVC 0 OTHER <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />0 Yes 0 No Boring Dia: Casing Die: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 2 <br />WELL IDs MW-7 and MW-107 <br />GROUT SPECIFICATIONS Neat cement containing <4% bentonite <br />TREMIE TYPE TO BE USED 1=1 AUGERS [11 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of ** inches to depth of ** feet <br />El PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />1=1 MUSHROOM CAP 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: ** See attached table for well construction details for information marked " ** " <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaqu Cot,sfltOrdinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print NameGregory Stahl <br />Title/Company( VP Ground Zero Analysis, Inc. <br />Date 1 7 <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: / Z.4 <br /> <br />v•A--kar-Lilstv#^ftrI <br /> <br />/ -1 <br /> <br />FA Name il,c'/ FA Address /6ssfo 14. jr Te4f,(A# FAcoz...,.7 PR# pecosil 24 yil <br />FA PE 74 6 0 <br />WP Reviewed By <br />115 447 <br />Work Plan Date 9L.211 7 t- 11 ii , <br />12'6:4.57 0 C-57 Authorization for Other to Sign Permit EKNorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit Ea/Access Agreement 12'Lead Agency Approval EKA' R <br />COMMENTS/CONDITIONS:A[ <br />a <br />i <br />t-L (1-Ni ()-040J- 4"k( ca....pc, p A ,u — bc_ cers,j7-24-1Z.e.c.C. <br />—WP TYPE PESc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 10",0 Z, ;/..) $152X 7.... / $0 ir 0760 iv- r 4 003 76 24 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application