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�;. SAN JOAQUIN COUNTY RE C E I V E <br /> ENVIRONMENTAL HEALTH DEPARTMENT ]UL 0 5 2016 <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.slce4)j6WNMENTAL HEALTH <br /> SITE MITIGATION WELL & BORING PERMIT APPLICXfl6WERICIS <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appikzbon Is hereby made to San Joaquin County for a permit to construct andlor install the work described. <br /> This application Is made In compliance with San Joaquin County Develolxnent Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 1iQ22 Tier.nr� (Zm.c� Cltyl3tat60P tea',- CA Phone <br /> Cross Street APN <br /> Property'owns Phone 209-J&30-32�LS <br /> Address Clty(Statercip Trrrcy. CA 253 6 <br /> C-57 QxTbactor <br /> tx�c \-"- a `-A -t� \ \ o ucen"# - '1 - \00"741 Phone lul-3-1`�- `t30�' <br /> Address Sd Cltyfstate2fp c� Q`-{S <br /> Consultant/Sub-Contractor GftD S,.��G. Llcens" Phone 910-420-15al <br /> Address 5900 Hft11ts ���.. Sc,.�C Q CtWStat&0p Ernc-rWMA CA !jVng <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note. Oftite BoringsdWells Require Access AWeemants or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATIM TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH LS T't. ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ ExTRACTTDN(Vap-Water) ❑ HAia+EwDFMN Du OF BOREHOLE y" ❑MILTIPLE C&UN GS❑uuL REVEL WELL CASING DIA <br /> ❑ SOL VAPOR PROBE ❑ ISD ROTARY CASING THICJDEM TYPE OF CASING ❑STEEL ❑INC ❑OTHER <br /> J4 SOI.BORING ❑ PUSH POrR(GPI CPT) CONDUCTOR CASING ❑Ya❑No Boft me Camp Db. CaraYq Dot <br /> ❑ tNJEC'TION T'HAND AUGER GROUT SEAL DEPTH TREMIF TYPE TO BE USED, ❑ANGERS ❑HOSE 101PPE <br /> ❑ OTHER ❑ OTHER. GROUT SEAL PUIFED7 ❑Ya" "ilr4 Arefr"Frndal Do*k JO FQ <br /> wmu sm aoRINT Da 9-vs-13-i6, fj_GROUT SPECFTCATXM <br /> g-20—5- <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECIc ALL THAT APPLY► <br /> 8 WELLS TO BE DESTROYED ❑OVERBORE I)VUETFR of irdm b dept of fat <br /> WELL IDs ❑PRESSURI:GROUT To de of feel below Kurfaa <br /> GROUT SPECIFICATgNS ❑EXPLOSIVES From b (set beiow slrbw <br /> TREMIE TYPE TO BE USED ❑AUGERS LJ HOSE ❑PIPE ❑MUSHROOM CAP D 3 feet below surface or�%M below surface a>3 feet - <br /> COMMENTS: <br /> I hereby codify that 1 am authorized to a mpiete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codas and Standards,and all other applicable California laws. <br /> Signed TitlelComperly S f G�►o5:�s l GqD <br /> P n n t N w1Ce Wilsoh_ Date 6/2-9114 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By. AX,-,,I}�� / I Date Issued: <br /> Grout Inspection BylDates: yd / C_LTi✓/7 -�d/fC�q w` r/1�� tcc f �rc.2�c> ����ln <br /> Destruction Inspecbon By/Dates: <br /> Facility/Site Information <br /> FA Nr FA Address T Ful# OO Z.3 Z PM <br /> FA PE I I WP RO*WW By I Waft PTen Dab <br /> ❑M 0 c-Phiii1a a m for oew to so Pam ❑Wafers cane ❑Waiters CwP Wdw ❑E wv**m r Pwdt ❑Aamn A ffammd ❑Lae AWwy App" ❑NFR <br /> COMMENTSICOND NS: any,f Sl✓e �G�.��-G�°✓�(y / l}I�ec� /r h�c t Cio�//!rs[�P '. t <br /> a(opro�ue. /lla a.�drfdryr� ,jao�:ryr bF a del rrej UAd--4CL;, �e✓ru:+ {' <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK* RECV'D BY DATE SERVICE REQUESTS INVOICED <br /> Work Plan <br /> Permit 2X25' 313 13o x 3 -Yz- 4; 79b It 9 8 7 cnir S1Maa7-5-l85 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />