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1 <br /> oPsalN'• SAN JOAQUIN COUNTY <br /> r. . ENVIRONMENTAL HEALTH DEPARTMENT <br /> N � <br /> `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> • 'ik' 'dN c Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <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 /> 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 Stockton Metropolitan Airport. 5000 S Airport Way City/State/Zip Stockton. California 95206 Phone (209) 468-4700 <br /> Cross Street Arch Airport Road APN 177-260-470 <br /> Property Owner County of San Joaquin Phone (209) 468-4700 <br /> Address 5000 S Air orp t Way Clty/State/Zip Stockton,California 95206 <br /> C-57 Contractor M R Drilling License# C-57#740854 exp. 9/30/25 Phone (714) 994-0402 <br /> Address 13124 Firestone Blvd. eitylState/Zip Santa Fe Springs, CA 90670 <br /> Consultant/Sub-Contractor BSK Associates License# n/a Phone (559) 497-2880 <br /> Address 3140 Gold Camp Drive#160 City/State/Zip Rancho Cordova, California 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: O(fsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> El MONITORING 1 1@ HOLLOWSTEM BORING DEPTH annrox. 6nff IM BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vap%Maler) ❑ HAMMERfDRIVEN DIA.OF BOREHOLE R" ❑MULTIPLE CASINGS❑MULTFLEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ®No Boring Do: V. Casing W: 2" Casing Depth: 60ft <br /> ❑ INJECTION WrSoaae.Omn) ❑ HANDAUGER GROUTSEALDEPTH Depthofboring TREMIE TYPE TO BE USED: ❑AUGERS []HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Matimum Freefall Depth Is 30 F9 <br /> WEW SOIL BORING IDs MW-R. GROUT SPECIFICATIONS Neat cement with s%bpntonite. <br /> See attached worknlan. <br /> DESTRUCTION WORK TO BE PERFORMED: n/a DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELL IDS ❑PRESSUREGROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface <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 Ordinance Codes and Standards,and alllother applicable California laws. <br /> Signed /�n TRIe/Company IS <br /> /ry rfjC.j_ ��f)IAGi f /QStL �. <br /> RDi Lt ^ 'Off /?�Z.3 Print Name (9VtlI /r /Gw I r1 Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: - Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Faci It /Sf a orma <br /> FA Name I FA Address 1 r p FA# jk4 I fill I PRU <br /> FA PE I WP Reviewed By I I Work Plan Date <br /> ❑C57 C-57 Autlxdzetion for Other to Sign Permit ❑WerWsOmp ❑Workers CanpWaiver ❑Encroachment Permit '❑Access Ageoment Lod AgencyApprval MFR <br /> COMMENTS/C NDITIONS: -r tv y�7.w✓ (�FM,C � r� tiv.5 r � llrti� /�),.� w-..�. <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan I <br /> Permit ').Gtfj ( <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />