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SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY <br />Grentness nrowc here <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 525 WEST FREMONT STREET <br />Cross Street WEST FREMONT ST / NORTH LINCOLN ST <br />Property Owner" WILSON, ROLAND <br />Address 15820 S HARLAN ROAD <br />C-57 Contractor GULF SHORE CONSTRUCTION SERVICES <br />City/State/Zip STOCKTON, CA 95203 Phone (209) 467-1006 <br />APN 137-214-11 <br />Phone <br />City/State/Zip STOCKTON, CA 95330 <br />(916) 939-4117 License# C57-964224 Phone <br />Address PO BOX 1501 City/State/Zip SHINGLE SPRINGS, CA 95682 <br />Consultant/Sub-Contractor AGE <br /> <br />License# 680227 Phone (209) 467-1006 <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM BORING DEPTH <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS <br />BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: El STEEL 1:1 PVC 0 OTHER <br /> <br />SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING <br />INJECTION (Air Sparqe, ()zonal El HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS <br /> <br />0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 2 <br />WELL IDs MW-3 AND MW-8 <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />GROUT SPECIFICATIONS PORTLAND CEMENT TYPE II <br />TREMIE TYPE TO BE USED M AUGERS D HOSE ['PIPE <br />E OVER-BORE <br />IJ PRESSURE GROUT <br />['EXPLOSIVES <br />El MUSHROOM CAP <br />DIAMETER of 8,25 inches to depth of 31 feet <br />To depth of feet below surface <br />From to feet below surface <br />3 feet below surface or feet below surface if >3 feet <br />COMMENTS: SEE WORK PLAN DATED 12 FEBRUARY 2018 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Saq Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed \-,(AtAA. <br />Print Name ERIN ROTTACKER Date 12 FEBRUARY 2018 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/ Site Information <br /> <br />Date Issued: <br /> <br />Ict <br /> <br />FA Name ''''' t CAI-A/4441.1 ' <br />GI i•S----,AtiLk%ryes <br />FA Address 511 0 Tre.,,,,,,A. sA- FA# 001.3.uc1 2,_ PR# C,S1-ti-S73 <br />FA PE <br />,- <br />L'' WP Reviewed By L --y Work Plan Date 2_1,-2118 <br />0 C-57 12fC-57 Authorization for Other to Sign Permit EKWorkers Comp 0 Worker's Comp Waiver 0 Encroachment Permit Ericcess Agreement eLead Agency Approval 19/MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit .,o., i l'• $152x ..,2_ t 4.4 1.',41,- I - - 3P1 k Imj ilUilA 02.31 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application <br />Title/Company STAFF GEOLOGIST / AGE