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ultv SA N..J 0 AQ U I N Environmental Health Department COUNTY °qP Greatness grows here. 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 48 Hours Advance Notice Required For All Inspections 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 23565 Santa Fe Road City/State/Zip Riverbank, CA 95367 Phone Cross Street Henry Road APN 249-070-110-000 Property Owner* Gustavo and Evangelina Guzman Phone Address 23565 S Santa Fe Road City/State/Zip Riverbank, CA 95367 C-57 Contractor V&W Drilling License# C-57#720904 Phone Address 1133 Blackhurst Drive City/State/Zip Galt, CA 95632 Consultant/Sub-Contractor Condor Earth License# PG#6795 Phone (209)743-7443 Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Saarae,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) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED 4 -- DIAMETER of 8 inches to depth of 5 feet WELL IDs S-16. S-18 S-19, S-20 PRESSURE GROUT To depth of 43 feet below surface GROUT SPECIFICATIONS 94 Ib cement/5-6 gallons of water ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED JZ AUGERS [:]HOSE [IPIPE ElMUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Sparge wells are 3/4-inch diameter and cannot be overdrilled and removed, so instead will be pressure grouted and overdrilled only to 5 feet. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable C liforn_ialaws. Signed_ � Title/Company jP� l e l CO r 60 r t3""-k-� Print Name �d�v� �L Date S �o DEPARTMENT USE ONLY c^ Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name '�0 h FA Address 27 C � r r FA# !,O I ` PR# g Z FA PE � �O WP Reviewed By 7✓ v Work Plan Date "��Gi / ❑C-57 G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver Effincroachment Permit ❑Access Agreement ❑Lead Agency Approval' ❑MFR COMMENTS/CONDITIONS: PrQSSure, -� aCs{►-P.2o1 —�'O �� G i Q 12 ?019 0 f rreJ-V t*-[ ,16 $10 al-a,ps . Any oil WP TYPE P SC PEE INFO JAMT REMITTED 6FE114 I REC 'D BY DUE WELL PERMI INVOICE# � i Permit V 0 70 $152 x S 159b S �� 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 OB-01-17 or$ite Mitigation Well Permit Application 7 ZC7