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Stockton, CA 95206 City/State/Zip <br />APN 163-230-080 <br /> <br />License# 710079 <br />City/State/Zip Rio Vista, CA 94571 <br /> <br />License# PG 5023 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: <br />TYPE OF WELUBORING NUMBER <br />El MONITORING 0 <br />EXTRACTION (Vapor/Water) 0 <br />SOIL VAPOR PROBE 0 <br />SOIL BORING 0 <br />INJECTION (Air Spam, Ozone) <br />OTHER <br />WELU SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> <br />DIA, OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? U Yes 0 No <br />GROUT SPECIFICATIONS <br /> <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />Environmen,,... Health Department SAN JOAQM <br />COUNTY <br />('--,atness grows 1-711." <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 1245W. Charter Way <br />Cross Street <br /> S. Fresno Street <br />2306 Jackie Court Oakdale, CA 95361 Address City/State/Zip <br />C-57 Contractor <br /> Woodward Drilling Co., Inc. <br />Address PO Box 336 <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />Address 1172 Kansas Avenue <br />Phone 209-848-3272 <br />Phone 209-848-3272 <br />Phone 707-374-4300 <br />Phone 209-522-4119 <br />Property Owner* Geo Properties, Inc., George Betker <br /> <br />City/State/Zip Modesto, CA 95351 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 1 <br />WELL IDs IW-9 <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of 15 inches to depth of 25 feet <br />P PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />12 MUSHROOM CAP Ca 3 feet below surface or feet below surface if >3 feet <br />GROUT SPECIFICATIONS See Tables and Work Plan <br />TREMIE TYPE TO BE USED I AUGERS I=1 HOSE Eg PIPE <br />COMMENTS: This well has a 6 inch casing <br />Signed <br />Print Name Gregory Stahl <br /> <br />DEPARTMENT USE ONLY <br /> <br />Date Issued: 3-17 Ii <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name /e-- v-, {' - FA Address kf-2 (f<F ‘` FA# in c 2 2.-:>.- PR# 0 i-4 , . <br />FA PE ,)-Chz, d WP Reviewed By L— X Work Plan Date ,S-7? A i ) e <br />0 C-57 0 C-57 Authorization for Other to Sign Permit n<Orker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement ar‘ad Agency Approval 1:14FIR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit -z,,i /02._. 33 $152x I t /57- 313g .„ Y /7/it (,-)r000b2-1 <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 />I hereby certifythat I am authorized to complete this application and that the work will be done in accordance with <br />San Jo uin ChyOrdinance Codes and Standards, and all other applicable California laws. <br />..-- Title/Company PG / Ground Zero Analysis, Inc. <br />Date 7 I.