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SAN,JOAQUIN Environmental ent <br />lir:196 1) COUNTY— <br />'c'41111:-ei Greatness grows here. NAY "I 201a <br />SITE MITIGATION WELL & BORING PERMIT APPI4 <br />For Wells and Borings Used for Contaminant Investigations and Rem <br />NON-REFUNDABLE 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 1141W.Charter Way Stockton, CA 95206 City/State/Zip Phone <br /> <br />Cross Street S. Fresno Street APN 163-230-110 <br /> <br />Property Owner* Linda S Miles Trust Phone <br /> <br />Address 629 Stardust Lane City/State/Zip Los Altos CA 94024 <br />C-57 Contractor V&W Drilling, Inc. License# 720904 209-469-7700 Phone <br />City/State/Zip Galt, CA 95632 <br /> <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. LIcense# PG 5023 Phone 209-522-4119 <br />Address 1133 Blackhurst Drive <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 WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />0 SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />0 INJECTION (Air Some. °met 0 HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs <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? DYes 0 No <br />GROUT SPECIFICATIONS <br />o BOLTED TRAFFIC BOX 0 STOVE PIPE <br />O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> <br />Boring Dia: Casing Dia: Casing Depth <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE (D PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 1 <br />WELL IDs MIN-1 <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />al PRESSURE GROUT To depth of 38.1 feet below surface <br />El EXPLOSIVES From to feet below surface <br />M MUSHROOM CAP Ea 3 feet below surface or feet below surface if >3 feet <br /> <br />GROUT SPECIFICATIONS Pressure Grout <br />TREMIE TYPE TO BE USED El AUGERS [21 HOSE EPIPE <br />COMMENTS: Refer to Well Destruction Table, Grout Calculations and Well Destruction Work Plan for well specific information. <br />Signed <br />I hereb <br />'Z' <br />certify that m au <br />San Joe <br />?a <br />n Co <br />/ <br />*.--1 <br />rized to complete this application and that the work will be done in accordance with <br />ance Codes and Standards, and all other applicable California laws. <br />Title/Company PG / Ground Zero Analysis, Inc <br />Print Name Gregory Stahl Date 5-3)- a 0) <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates, <br /> <br />Date Issued: <br /> <br />151 <br /> <br />Destruction Inspection By/Dates. <br />Facility/Site Information <br />FA Name .sfi''',, -- .-.16'1,4/4"P"'"'"" <br />Cu v \.--fetAn <br />FA Address t 2-44,1- vj ' (-14"--i'v" `,-----/ FA# _ , c-k -z_i_/ l? 7'' PR# ,-.<7 4 7 ?,r , : <br />FA PE -3914 -C WP Reviewed By L, y Work Plan Date <br />lef, <br />0 C-57 0 C-57 Authorization for Other to Sign Permit (1),Workers Comp ID Workers Comp Waiver 0 Encroachment Permit D Access Agreement 0 Lead Agency Approval D MFR <br />COMMENTS/CONDITIONS: , "I v., i, 1,,,e_ c ,,_ ,,, , ,_,„ <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit :251,0,2_ --s i- $152 x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.corn <br />END 29-01 08-01-17 Site Mitigation Well Permit Application