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°�I 0o c" SAN.J OAQU I N Environmental Health Department COUNTY cq�+Fot;��P Greotness 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 23569 Santa Fe Road City/State/Zip Riverbank, CA 95367 Phone Cross Street Henry Road APN 249-070-120-000 Property Owner" Munir Obaid Phone Address 2616 Acapulco Way City/State/Zip Modesto, CA 95355 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 WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN 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 Saarge,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) ,1� WELL/SOIL BORING IDs GROUT SPECIFICATIONS It S I I „ ml l fC 1 d ' Qr 'cr Xr 1 Va r;,,-d �.p DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED 27 VER-BORES DIAMETER of inches to depth of feet WELL IDs AS-1. V-1 through V-10 S-1 through S-15 and S-17 PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS 94 1bp cement/5-6 gallons of water ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED JZ AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: See Attachment A. Sparge wells(S-X)are 3/4-inch diameter and cannot be overdrilled and removed, so instead will be pressure grouted and overdrilled only to 5 feet. Vapor extraction and AS-1 wells will be overdrilled to full depth. 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 California laws. Signed 1 I�"-'�� Title/Company &' Z Ctg ( ✓� Print Name Yi.Y1� Date EPARTMENT USE ONLY Application Accepted By: V Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: VV 0 Facilit /Site Information FA Name f/m,Q {� / ,, FA Address _CV,r ,- rP FA# po .3 PR# 6 5717 FA PE 2 6 WP Reviewed By QW6�L, Q 9 Work Plan Date 1 'L/1 18 ❑C-57 G57 Authorization far Other to Sign Permit ❑Worker s Comp ❑Workers Comp Wai Encroachment Permit ter❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CO IT st V I 4hra V rk S I {o he, over r;( $.apt. emxj Corn3F r*je*4w/ MV—:r tee. y$ fl►rtt V�� S� .(-hra 3 $ (3) ��', S15, and SI-4 4e be re�urc ro�ff WP TYPE I PE I SC FEE INFO AMT REMITTED CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# Permit Z107- 3(3 $152 x Z " - 15$ 3// 0 Ott 0 3 1868 E. Hazelton Av nue I Stockton, Califgrnia 95205 1 T 209 468-3420 209 464-0138 1 www.sjcehd.com EHD 29-0 1 0oe-01}17 Q� �0 ` i-, V v f,� O J /✓l!`k"Site Mitigation Well Permit Application *4 30' 0Q` "� `J 'r C — o-,- (ev�i'