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0,4 4; —COUNTY — <br />SAN JOAE.N () 1= <br />, <br />.. <br />Greatness grows here. <br />Environme 31 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 <br />Cross Street Highway 33 / Durham Ferry Road <br />Property Owner* Seeds of LifeNerbum Del / Ellen Hess <br />City/State/Zip Tracy, CA 95304 Phone 209-522-4119 <br />APN 255-310-023 <br />Phone 415-533-0322 <br />Address 3365 le Street City/State/Zip San Francisco, CA 94110 <br /> <br />License# 720904 Phone 209-469-7700 <br />City/State/Zip Galt, CA 95632 Address 1133 Blackhurst <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />Address 1172 Kansas Avenue <br />License# 5023 Phone 209-522-4119 <br />City/State/Zip Modesto, CA 95351 <br />C-57 Contractor V&W Drilling <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Sparcie, Ozone <br />OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING El Yes 0 No <br />GROUT SEAL DEPTH <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Bonng Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 Na (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 3 <br />GROUT SPECIFICATIONS Neat cement containing <4% bentonite <br />TREMIE TYPE TO BE USED CI AUGERS I=1 HOSE El PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />Z OVER-BORE DIAMETER of ** inches to depth of ** feet <br />PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP 3 feet below surface or feet below surface if >3 feet <br />WELL IDs SW-101 MW-6 and MW-106 <br />COMMENTS: See attached table for well construction details for the 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 Joaq Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br /> <br />Title/Compan VP ',Ground Zero Analysis, Inc. <br />Print NameGregory Stahl <br /> <br />Date <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />50 I,V/i'Z//il <br />DEPARTMENT USE ONLY <br />Date Issued: 2/// <br /> <br />FA Name Fcif ewix- 6 4._eicyji Solt_ FA Address /6 VD if Dv , ividt4L Tacci FA# Fk 06 7, ; 7 Jo PR# fit71 z1'ss,-4, <br />FA PE "2-1 ‘ 0 WP Reviewed By z t4/------- <br />Work Plan Date .7 <br />Z57 El C-57 Authorization for Other to Sign Permit ErWorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 1;li‘cess Agreement Igt<e'a-d Agency Approval ILK <br />COMMENTS/CONDITIONS:We/4.a' oe &Let...) d,,,,,,i,x5 rA4,- imAk.2. 4- h-c.. e_evca-tA4-1,,e-ci---z_.••1 • <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 2)1 1„ u3 $152x 3 /1-a 3076 0 itt---- ii 'z/1 wf D'o '37 6 2—Z---- <br />1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 www.sjcehd.com <br />END 29-01 06-01-17 Site Mitigation Well Permit Application