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SANssJOAQUIN <br /> Environmental Health Department <br /> ' —COUNTY— <br /> Greatness, <br /> grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Welts and Borings Used for Contaminant Investigations and Remedtation <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 351GO South HI hwav 33 City/State/Zip Vernalls CA 95385 _Phone 209.835.7597 <br /> Cross Street South Welty Road APN 25-518-008 <br /> Property Owner` Nutrient A Solutions Inc. Contact-Kevin Bertrand Phone 303.261.2982 <br /> Address 5296 Harvest Lake Drive CitylStatelZip Loveland Colorado 80538 <br /> C-57 Contractor Cascade License# 1058336 Phone 713.863.0000 <br /> Address PO Box 1184 City/State/Zip Woodinville Washington 98072 <br /> Consultant/Sub-Contractor Rubik,Sieve Meninger-Senior Geologist License# CA-PG No.8853 Phone 775.432.0247 <br /> Address 320 Flint Street City/State/Zip Reno NV 89501 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS BOLTED IM"lC BOX STOVEPIPE <br /> HOLLOW STEM BORING DEPTH _ <br /> [I EXTRACTION(VaMMlater) ❑ HAMMERIDRNEN DIA OF BOREHOLE _ _❑MULTIPLE CASINGS❑MULT4LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS_ _TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPICPT) CONDUCTORCASING Ao Bming Dia: Gasing Dia: Gasing Depth: <br /> ❑ INJECTION(Aklio Ooeie1 ❑ HANDAUGER GROUT SEAL DEPTHRO � TRyyE,,MIETYPE TO BE USED: ®AUGERS El HOSE [I PIPE <br /> [I OTHER [I OTHER UT SPEC PUMPED? w <br /> SEAL TIONS®Yeas No IN (' PFre tal^Depth 30 FQ <br /> WELUSOIL BORING IN MVJ3R.MW4R.MWdR.MWER,and MWER GI t <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION M HOD: CHECK ALL THATAPPL G <br /> #WELLS TO BE DESTROYED a ®OVER-BORE DIAMETER of 10 inches to depth of >na feet <br /> WELL IDs MW-1 2 MW3 MVJA MN/-6R and �77 ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS neat cement El EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below sudace if>3 feet <br /> MENTS: <br /> Wallow ver-bere tetel-deritI1TT . MW-1, MW-2 and MW-3:TO=49'.MIN-4, MW-6R and MW-7:TO=45'. <br /> reby certify that 1 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 /lu-4r`L 9 Title/Company N i A Saw 1 /s M nape, EnWr wtal Remediatbn <br /> Print Name Kevin Bertrand Date .tune 3, 2020 <br /> DE RTMENT USE ONLY / 20 -� `, <br /> Application Accepted By: Date Issued: Lam/ <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit ISHe Information _ <br /> FA Name t H�I�S FA Address 3.� IDD -�"t,4 33 fA# © � Z 1 P •7� 7 <br /> FA PE L O WP Reviewed By Work Plan Date 6 Z Z <br /> ❑G-57 G-57 Auihoma neforr Other to Sign Permit ❑Workers Comp ❑Workers Comp Waver ❑Encroachment Permit ❑Aaess Ali <br /> —element [I Lead Agency Approval ❑MFR <br /> COMMENTS/ ON ITIONS: �`Q m;J/ � Alt /� <br /> Wp TYPE PE SC FEE�I INFO AMT REMITTED /C'+HE/C�K# ECV'0 B ATE WELL PERMIT# INVOICE# <br /> Permit ZgoZ �13$152x S C <br /> 1868 E. Hazelton Avenue I Stockton, California 95206 i T 209 468-3420 i F 209 464 OSita Midge on WellAPe mR Appi-cawn <br /> ?COm <br /> EHD 29-01 ee-01-17 <br />