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RECEIVED N G SAN JOAQUIN COUNTY @!� ? ZO17 ENVIRONMENTAL HEALTH DEPARTMENT 14: '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 `NVIRONMENALHEALTH ..... N% Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com PERMIT/SERVI, 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 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in pliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address �� L-'(/GkER r� N /10�D City/State/Zip 5roGk7'oN, "4 9sao6 Phone Cross Street A'CGESS RO 9-D APN 12-1 -06 _ OO by I¢Aµ Property Owner' ,xWC1 =1C, t%1/4s ELEGni c caehproN�/ RSP ',T' 1504 Phone 9L5-Zy4� 3y OZ Address City/State/Zip C-57 Contractor G9 S C400E p12I"I rrc7 LP License# ?.?,6110, 6XP 9/30/l3 Phone 1/6 403 ' 1�F fZ-e Address N111 City/State/Zip Consultant/Sub-Contractor C-70406,11 1000e,/hff6 S /AIL." License# Phone 916'360 -33 38 Address 7000 5&?7Sapjl&ISe evsILy, elm /'f® City/State/ZipRoSEV/GbE, C4 9$'6 -7 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING HOLLOW STEM BORING DEPTH 10 to 2:o r ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE 9 I NC44 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER N SOIL BORING 114 ❑ PUSH POINT PP/CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia Casing Dia: Casing Depth. ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER Z—�0 OTHER: GROUT SEAL PUMPED? El Yes El No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs f i rljM� 00lkl IS—I q GROUT SPECIFICATIONS &C6-7- &FM,=NT W /3ErvT9N tm G N^1 VS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs -- ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATION ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE ED []AUGERS ❑HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 4veL 6b c4 vv -;rR.(inaty r•Y 4-r- l 134la I WGt LO&e4-noN, fAL.i, r$pYLfc +1j (. I(,4 190F d wL>r p t-.-i714 II CAG�w-QtiT &X 917-t4vN tM Gy-fX- I hereby certify that I am authorized to complete this application and that the work will be done in accordance with J� San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Sied C Title/Company piesiyi/;' i5N4jff&R /G-O We 65;w4Wss AA Print Name Q4t?1501 A9t/L C• ER4(/k$0r -J Date 6/ DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC I FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# Permit $139 x EHD 29-01 10-26-2015 Site Mitigation Well Permit Application