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SAN JOAQUIN COUNTY RECEIVED 2` ENVIRONMENTAL HEALTH DEPARTMENT AUG 0 2 2017 a •: 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.siceh " E'.f�M FAL HEALT" �dfi F o kii�P �IdIT+fSER1HCES SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 7647 Pacific Avenue City/State/Zip Stockton, CA 95207 Phone (209)476-8669 Cross Street Rivara Road APN Property Owner* City of Stockton Phone (209) 937-8381 Address 425 N.El Dorado St City/State/Zip Stockton, CA 95202 C-57 Contractor Gregg,Drilling&Testing License# 485165 Phone (925) 313-5800 Address 950 Howe Rd. City/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor ATC Group Services LLC License# Phone (209) 579-2221 Address 1117 Lone Palm Avenue, Suite 201B City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS M MONITORING 2 ® HOLLOW STEM BORING DEPTH 45 &80 . ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS sC . 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes M No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(A4 soame.ozonel ❑ HAND AUGER GROUT SEAL DEPTH 25 &70 ft.TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? M Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs MW24 and MW25 GROUT SPECIFICATIONS neat cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with S n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company:Roao,,�, bP" dTC aj" 5,t.r'(,«,_, Print Name Date d O( l EPARTMENT USE ONLY Application Accepted By: Date I Jsued: J Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name ; M(V FA Address � 1 F6 ` t.W"`�' FFA# 1 00 PR# Q;—L4 1-t LX� No . 2 FA PE WP Reviewed By L-N Work Plan Date S . , i 7 C-57 ❑C-57 A uthorization for Other to Sign Permit ©'Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency Approval M,%fFR COMMENTS/CONDITIONS: kwL* h.o a,✓5 ,� ,s( �...�.ee ��„A i� t�lw� lJr' SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY x�DATE SERVICE RE�tQUEST# INVOICE# Permit >Cie '3 1� r x Z EHD 29-01 10-26-2015 Site Mitigation Well Permit Application