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<br />Date Issued: -7/1 -z fig <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates <br />Facility/Site Information <br />ARTMENT USE ONLY <br />SANJOAQUIN Environmental HeiikOlk ment <br />COUNTY <br />Greatness grows here. tlAY 3 2018 <br />For Wells and Borings Used for Contaminant Investigations and Rertialiatipk, HEALTH <br />"1- <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 1145W Charter Way Stockton, CA 95206 City/State/Zip Phone <br /> <br />Cross Street S. Fresno Street APN 163-230-120 <br /> <br />Property Owner* Linda S Miles. Trust Phone <br />629 Stardust Lane Los Altos CA 94024 Address City/State/Zip <br /> <br />C-57 Contractor V&W Drilling, Inc License# 720904 209-469-7700 Phone <br />SITE MITIGATION WELL & BORING PERMIT APPL1 <br />Address 1133 Blackhurst Drive City/State/Zip Galt, CA 95632 <br /> <br />Consultant/Sub-Contractor Ground Zero Analysis. Inc. License# PG 5023 Phone 209-522-4119 <br />Address 1172 Kansas Avenue City/State/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />El MONITORING 0 HOLLOW STEM BORING DEPTH 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />SOIL BORING 0 PUSH POINT (GPI CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth. <br />INJECTION (Air Sparge Ozone( 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER Ci OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 3 <br />WELL IDs MW-2, MW-3, MW-8 <br />GROUT SPECIFICATIONS RafFir tn Tablas R. Z/nrk Plan <br />TREMIE TYPE TO BE USED la AUGERS El HOSE gat PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />ff OVER-BORE DIAMETER of * inches to depth of feet <br />PRESSURE GROUT To depth of * feet below surface <br />I=1 EXPLOSIVES From to feet below surface <br />M MUSHROOM CAP Ca 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />* Refer to Well Destruction Table, Grout Calculations, and Well Destruction Work Plan for well specific information. <br />I hereby certify that I am autijorized to complete this application and that the work will be done in accordance with <br />San Joaq4h Cofty Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company <br /> <br /> PG / Ground Zero Analysis, Inc. <br />Date Print Name Gregory Stahl / <br />Signed <br />FA Name I;j, _'.7.4iLL' f "s4V' <br />L>.- A ....".... <br />FA Address .-4-s: `,P-1 • (--L*4-efr" kA-4rvi FA# PR# <br />FA PE OA . WP Reviewed By t A'' Work Plan Date si a i i i x- <br />0 C-57 0 6-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: es .....- A <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <br />I tiSlo L --)( -7 lit-114- v4Por51 <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