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s t i LSf y r ) ` SAK J0A0UIN Environmental Health Department :4# I: COUNTY (rr'?Otriess 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 /Devvelopment Title,Chapter(9-1115.3,and /the San Joaquin County Well Standards. Job Address i tu�i1 � ' O Uh 0 6`�) E t (, W( City/State,'/Zip l)`JC-JI(��N V7 Phone Cross Street _ A t.5�q 5 5' APN j ,)J g Property Owner* Ci 0f, L Phone Xv 7 Address 3 5AC-band S City/State/Zip 5bt,((k" V+154j-2, 2 >7 l C-57 Contractor Q , AW' r License# Phone l(�/41--Jl(3-(I J55 Address C CA0(dil1'/� City/State/Zip Qt dpi o 11.5'NZ, �" 7, Consultant/Sub-Contractor Ui + , License# (� Phone .-53o-l(�V-Xk Address %3D Vh 1 &1 10 U City/State/Zip Cqp&J7n P CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLBORING 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)52-e wr V 4y) #WELLS TO BED STROYED 2 OVER-BORE DIAMETER of inches to depth of feet w c+ WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS '' n�)X ❑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 San Joaquin County Ordinance Codes and Standards;and all other applicable California J '1 1aws. Signed �U Title/Company r1OJ eU�Gi -S1r Print Name ��(} t Ri� Ir�,�� Date -��i-'� DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Namenw✓ Q`" "^`emu' FA Address FA# Zi Z( g PR# FA PE 2-0100 WP Reviewed By L ix Work Plan Date 1 '4 41 ' ❑G57 C-57 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp Waiver RrEncroachmentPemlit ❑Access Agreement El Lead Agency Approval R COMMENTS/CONDITIONS: B�, f�y ,,,v,� may �t aN yy ,Qi,� .s,o WP TYPE I PE SC ' FEE INFO JAMT REmiTTED1 CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit I .29OZ- 313 $152x sz 3aya ey5 6z I JA W5 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjrehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application w� Zq�U 3 5'Z,3 $62-x 3 9 sb �Is�s� `�/�lw 6(Loa 8,053j