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Phone 209-848-3272 Stockton, CA 95206 City/State/Zip Job Address 1245 W. Charter Way <br />Cross Street S. Fresno Street APN 163-230-340 <br />Property Owner* Phone 209-848-3272 Geo Properties, Inc. George Betker <br />2306 Jackie Court Oakdale , CA 95361 Address City/State/Zip <br />720904 License,* C-57 Contractor V&W Drilling, Inc. 209-469-7700 Phone <br />City/State/Zip Galt, CA 95632 <br />PG 5023 License# Phone 209-522-4119 Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />City/State/Zip Modesto. CA 95351 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 5 <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />24 OVER-BORE DIAMETER of * inches to depth of feet <br />WELL IDs MW-5, MW-7, IW-3, IW-4, OW-3 NRESSURE GROUT <br />Ej EXPLOSIVES <br />MUSHROOM CAP <br />To depth of * feet below surface <br />From to feet below surface <br />[X 3 feet below surface or feet below surface if >3 feet <br />GROUT SPECIFICATIONS See Tables & Work Plan <br />TREMIE TYPE TO BE USED [29 AUGERS J HOSE EJ PIPE <br />Signed <br />Date <br />I hereby <br />Print Name Gregory Stahl <br />ertify thatI a uthorized to complete this application and that the work will be done in accordance with fi <br />San Joaqui u ce Codes and Standards, and all other applicable California laws. <br />, Title/Company PG / Ground Zero Analysis, Inc. <br />sre <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />i'"'°---th"-cso(-. SA <br />COUNTY <br />csarmco:, ./ <br />Greatness grows here. iUY :5 1 2W8 <br />SITE MITIGATION WELL & BORING PERMITARLçTIdN <br />For Wells and Borings Used for Contaminant lnvestigationsn tlb <br />/!CEs <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 />610AQUIN Environ men ipq Department <br />CONSTRUCTION WORK TO BE PERFORMED: *Note Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF VVELLIBORING <br />MONITORING <br />EXTRACTION (VaporNVater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Sparse, Ozonel <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 TH' CKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes ID No <br />GROUT SPECIFICATIONS <br />COMMENTS: * Refer to the Well Destruction Method Spreadsheet, Grout Calculations & Well Destruction Work Plan for well <br />specific information <br />DEPARTMENT USE ONLY <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name .r:rj r r'‘-r Lir"' CI t'ir `;1 C.. es.....-1 -" t <br />FA Address '-i-S- vj : C ---1 -- --'p i FA# (7)0`1,-q 7!,s? PR# <br />FA PE ,)..321 V WP Reviewed By t Work Plan Date . Li i ti/ <br />0 C-57 (381-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Perrnit 0 Access Agreement 0 Lead Agency Approval 12 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit )41(it, -5 1 $152x <br />- 1 il 2-/P.t _ krJ ecz)3 cz---i <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <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 />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 />Address 1133 Blackhurst Drive <br />Address 1172 Kansas Avenue