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rized to complete this application and that the work will be done in accordance with <br />dinance Codes and Standards, and all other applicable California laws. <br /> Title/Company VP / round Zero Analysis, Inc. <br />S- 17 <br />I hereby certify that I am aut <br />San Joaqy1 Co <br />Signed <br />Print NameGregory Stahl <br /> <br />Date <br />SANAAQuIN <br />COUNTY <br />Greatness grows here. <br />Environmei.al 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 -88 FT East on Durham Ferry Road at the HWY 33 Intersection <br />Cross Street Highway 33 <br />Property Owner* San Joaquin County Dept of Public Works <br />City/State/Zip Tracy, CA Phone 209-468-3000 <br />APN County Right of Way <br /> <br />Phone 209-468-3000 <br />Phone 209-469-7700 <br />Phone 209-522-4119 <br />Address 1810 E Hazelton Avenue City/State/Zip Stockton, CA 95205 <br />C-57 Contractor V&W Drilling License# 720904 <br />Address 1133 Blackhurst City/State/Zip Galt, CA 95632 <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. License# 5023 <br />Address 1172 Kansas Avenue City/State/Zip Modesto, CA 95351 <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 Scarce, ()zonal <br />OTHER <br />WELL/SOIL BORING Ds <br />NUMBER INSTALLATION TYPE <br /> o HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> El 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 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? El Yes 0 No <br />GROUT SPECIFICATIONS <br />O BOLTED TRAFFIC BOX 0 STOVE PIPE <br />El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: 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 /># WELLS TO BE DESTROYED 1 <br />WELL IDs OW-1 <br />GROUT SPECIFICATIONS Neat cement containing <4% bentonite <br />TREMIE TYPE TO BE USED AUGERS Z HOSE Z PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of 10 inches to depth of 25 feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: See attached table for well construction details for some of the above information. <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issued: /// U/1 7 <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address /6 yo 1 J. D.‘00( kem.,.. 1,.ri..FA# \--Fravt z.,3 .7 0 PR# o-'- A. <br />FA FA PE <br />74 6c. <br />WP 'viewed By Work Plan Datey22/17 ...f 3 07 <br />1Z-'57 El C-57 Authorization for Other to Sign Permit FV4orker's Comp 0 Worker's Comp Waiver r2t(ncroachment Permit 0 Access Agreement V: Ages y Nz7I FR <br />COMMENTS/CONDITIONS:Wwki etti pt At _a dim..i,v, 1..,(-0„,_,,fs\i„.3 rA.4,0 4- be_ e.,„vje.A..ev...e.,cr . <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Perrnit Z/101_ 3/3 $152 x / f /S-2- 3o760 - 11 1 Z,1 kle ao 3 7 6 z-3 1A, <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 />41- trt )1 1