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1 <br /> SAN�JOAQUIN p <br /> Environmental Health Department <br /> COUNTY— <br /> Greatness grows 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 35100 South HighwaV 33 CitylStatelZip Vernalis, CA 95385 Phone 209.835.7597 <br /> Cross Street South Welty Road APN 25-518-008 Z�1-44 P— ?oo 0 <br /> Property Owner' - 5LI? iz0 N 1C /�.S Phone 363,267:4982- <br /> Address_52g6-I•ImVssr -o-e ^rive �$ I Q'7.2(I�y�CitylStatelZip Lgaehm , ep reem t" <br /> C-57 Contractor Cascade License# 1058336 Phone 71MBT 00 <br /> — <br /> Address PO Box 1184 City/State/Zip Woodinville,Washington 98072 Itz-5--54, <br /> Consultant/Sub-Contractor Rubik, Steve Meninner-Senior Geologlst 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: OHsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOWSTEM BORING DEPTH BOLTED TRAFFIC BOX STOVEPIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERMRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING []Yes ❑No Boring Dla: Casing Oia: Casing Depth: <br /> ❑ INJECTION(Atscame.ozael ❑ HANDAUGER GROUTSEALDEPTH TREMIETYPETO BE USED: AUGERS [I HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Yes [I No (Note:Maxlmum Freelall Depth is 30 Ft) <br /> WELU SOIL BORING IDs MWSRard MW-aR GROUT SPECIFICATIONS_ <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 ®OVER-BORE DIAMETERof 10 inches to depth of 145 feet <br /> WELL IDs MV,-5 and MW-a ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS neat cement El EXPLOSIVES From to feetbelowsurface <br /> TREMIE TYPE TO BE USED El AUGERS [I HOSE ®PIPE El MUSHROOM CAP ❑3 feelbelow surface or feet below surface if>3 feet <br /> COMMENTS: <br /> Wells will be over-bored to total depth(TD). MW-5: TD=45'; MW-8:TO=50'. <br /> 1 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 A'U-G/G g L , Title/Company NNden Ag Scgwons,Im./Sr Manager,EnNmnmental Remedaeon <br /> Print Name Kevin Bertrand Date June 3, 2020 <br /> ARTMENT USE ONLY w Application Accepted By: -- Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dales: <br /> Facilit /Site Information <br /> FA Name 10 FAAddfess 3 FA# �� 2 PRO <br /> L /�J ✓ <br /> FA PE 60 WP Reviewed By Work Plan Date /7� <br /> ❑C-57 ❑CS7AugronzationWOthvverlo Sgn Pemlit ❑Workers Camp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement El Lead Agency///Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE I SC FEE I JAMT REMITTED1 CHECK# I RECV'D BY I DATE W L PER IT# INVOICE# <br /> Permit I ZI0 3 13 $152 x I MIt I CLC 1�jIA/ 11Z Ito Pv rov Wo <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464 138 1 vvww.sjcPhcI.com <br /> EHD 29-01 ne-01-17 Site Mifigauon Well Permit Application <br />