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<br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />Environmental Health Department <br /> <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br /> <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br /> <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 Phone <br />APN <br /> Phone <br /> <br />Phone <br /> <br />Consultant/Sub-Contractor License# Phone <br />Address City/State/Zip <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING HOLLOW STEM BORING DEPTH BOLTED TRAFFIC BOX STOVE PIPE EXTRACTION (Vapor/Water) HAMMER/DRIVEN MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE MUD ROTARY TYPE OF CASING: <br />DIA. OF BOREHOLE <br />CASING THICKNESS STEEL PVC OTHER SOIL BORING PUSH POINT (GP/ CPT) CONDUCTOR CASING Yes No Boring Dia: Casing Dia: Casing Depth: INJECTION (Air Sparge, Ozone) HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: AUGERS HOSE PIPE OTHER OTHER: ____________ GROUT SEAL PUMPED? Yes No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS <br /> <br /> <br /> <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> OVER-BORE DIAMETER of ____ inches to depth of ____ feet # WELLS TO BE DESTROYED <br />WELL IDs PRESSURE GROUT To depth of ________ feet below surface <br /> EXPLOSIVES From ________ to ______ feet below surface GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED AUGERS HOSE PIPE MUSHROOM CAP 3 feet below surface or ________ feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed Title/Company Project Manager/Arcadis <br />Date 2/14/2025 <br /> <br />DEPARTMENT USE ONLY <br />Print Name Arianne Terry <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br /> <br />Facility/Site Information <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br /> C-57 C-57 Authorization for Other to Sign Permit Worker’s Comp Worker’s Comp Waiver Encroachment Permit Access Agreement Lead Agency Approval MFR <br />COMMENTS/CONDITIONS: <br /> _____ <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK#RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152 x <br /> <br /> <br />City/State/Zip Stockton, CA 95212 <br />20106003 <br />(209)601-2274 <br />Cross Street <br />Property Owner* Osvaldo Cordero <br />Address 7707 S Austin Rd. <br />C-57 Contractor ABC Liovin Drilling, Inc. <br />Address 1180 E Burnett St <br />Arcadis U.S.,Inc. <br />4119 Broad Street,Suite 210 San Luis Obispo,CA 93401 <br />(805)706-2805 <br />City/State/Zip Stockton, CA 95212 <br />License# 422904 <br />City/State/Zip Signal Hill, CA 90755 <br />(562)981-8575