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a '�•• SAN .IOAQUIN COUNTY RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT JUL 0 7 2091 K 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENALH d !`P Telephone:(209) 468-3420 Fax.(209) 468-3433 Web:www.sacehd.com PERMIT/SERVICES ArFO ` 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 A ation is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in piiance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards, Job Address 11 B1 'Z(pe N 20vr) city/StatelZip 5Tock7oN, CO 95206 Phone Cross Street 41:zoSS 4019-0 APN /Z ? -08 - 00 er` Pr9C(FI C 4&S by IRA H Property Own LEG c Cornpl4Ny rQ6y7JKIS0n! Phone 9Z5'Z44" 3y OZ Address City/State/Zip C-57 Contractor C9S G*VF vail wrrrG7 LP License# 938 /10, 6Xp 9130//3 Phone 9�6"NO;" }}ZB Address City/State/Zip Consultant/Sub-Contractor Cho 606 X Aff06nf1G f /NG. License# Phone 916-360-3318 Address /000 6rV16rlfelLJfe k*11' SVirm /qa , '-tylState/Zip 9oSEV/Le.iE, uq 9S•'6 ;t? CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringshVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING HOLLOW STEM BORING DEPTH /O ♦o yp r ❑.BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) HAMMERIDRIVEN DIA,OF BOREHOLE 9 /NOL( ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 1K SOIL BORING ❑ PUSH POINT /CPT) CONDUCTOR CASING ❑Yes,0No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION Iorsoeoe.O:anet ❑ HAND AU GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER!' GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Dektth is 30 Ft) WELtI SOIL BORING IOs /fJ'V r•r $�I GROUT SPECIFICATIONS .YEr4-T �!'ME/yr p7�fj'EWT9NlTL a411PS DESTRUCTION WORK TO E PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL IDs — Z ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATION =- [I EXPLOSIVES From_to_feet below surface TREMIE TYPE TOB ED F-1AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface I>3 feet COMMEli k S L.1L 44 PV 5rr,;oW e,*YV 9't Yh-N So)&I N<n Lv c44- 0", t91.L dcoai'e +Lr- err 0 w171 r'54-r &cw,QtiT &:t gswrwvI.re oylK. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �yJ San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Si ed�/ 1 �p<!I� Title/Company PPOJ15a J5-& I N&2 L6W";12 H:5!;W f4rFS (/�• Print Name—20W00,7 1049-flt C. EJC49:6SOr..J Date (0 'JVLy —70l7- 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 Camp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COM M ENTSICON D ITIONS: SR TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE SERVICE REQUEST# INVOICE# Peril 1$139 x EHD 29-01 10-26-2015 Site Mitigation Well Permit Application