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A4Uf CO.\ SAN JOAQUIN COUNTY <br /> �R•:�f <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N� < <br /> •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> qP • Telephone: /209` 468-3420 Fax: /209 468-3433 Web:www.sicehd.com <br /> �LFOR� C / <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,andtheSan Joaquin County Well Standards. <br /> Job Address 11011 �NowARo �� City/State/Zip STOCKIOP .. C�1, Phone <br /> Cross Street Imty OZV➢, APN <br /> J Phone 261-9 36 3 2 y� <br /> Property Owner" I RQLy i�wl.+ED �iGHb%i �+STRICT A �•• <br /> Address I 15 W. Lpwu AyE City/State/Zip I—RACY, eA 5J 376 <br /> C-57Contractor CAS PRILLINL License# 93eilb Phone $-93 �-I16q <br /> Address 3000 U LIATR ST. City/State/Zip V S,UKAMENTO} CA <br /> Consultant/Sub-Contractord , �l '3315 <br /> f I II� /S••&RY1LL5 �N�. License# Phone 5W z0 <br /> Address SW ouiI ST. }U+TC rt City/State/Zip t.,4lrh'W+LtE_ /,t� <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING `HOLLOW STEM BORING DEPTH FT-06❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVE_N DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ' `VC ❑ OTHER <br /> Ed SOIL BORING 17. Ej'PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge.Ozonel I'HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> d OTHER-NYYij16Pa.v6 l ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Ma)dmum Freefall Depth Is 30 Ft) <br /> WELL/SOIL BORING IDs1 Uk t 0-z GROUTSPECIFICATIONS <br /> I .1 [I -gJ iI i <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) i <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT 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: 11 94;jD Au6c)< o+itN65 'To '7;5 P7 GS TV e,:>LLBL'f 504. S410LE5; IiYDjjDr v,_N io )o r-r 66S ro <br /> CoL4-c-(_Tv",7aUH�w4TER >.�KitESj - 'moi <br /> a S �tI To r.Y E J L N'iTtCkFi I <br /> hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> an oaquiin County Ordinance Codes and Standards,and all other applicable California la S. <br /> Signed '� // ++ ' � 4� Title/�pany,� c�c� {-I� "mei <br /> Print Nax � y.(' IS�r�' IiRIc Ct1�ZOFF Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: �U�� ioG1ULV�+ Date Issued: ��I(e <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA AddreFA# 1 op 23525 PR# 05-411,081- <br /> FA <br /> 3S//08 -FA PE WP Reviewed By ' Work Plan Date 20 j4,ayttj 20/4 <br /> CIC-57 C-57 Authodzatlon for Other to Sign Permit 00orkers Comp ❑Workers Camp Waiver ❑Encroachment Permit ❑Access Agreement ead Agency Approval FR <br /> COMMENTS/CONDITIONS: eVvf &rrA s wt 1i pertk.-"d re-m4e—f-ne&—,- V�/�e1—1 —Z'o,•b iflf assay he`J/, <br /> li�/,7� /)iv>GvC fv// !c✓lti(fib/ l.�s�{ larlt r�tAeW Y <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 990 _,523 Mu 4,390 <br /> Permit Z*s 313 $130, 3 t w /I n 7 Y�0075'0 y <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />