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oP`��tn• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Vl: <br /> .'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com <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,and the San Joaquin County Well Standards. <br /> Job Address 11(4, i•JPSI WeNXf hJFl1,AC City/State/Zip ��-o�i�y�� (/} cfs-�-031Phone Al <br /> Cross Street Nor-K Un-6, 51m z)- APN 133 -3 <br /> Property Owner' 137-370-02 for SSGP-1 Phone °Z1 <br /> Address D O I City/State/Zip S�,4L� (A c(S LJ3 <br /> C-57Contractor T' (' P!J-A, - �a-� 5 License# Phone r8S 3 –J�1 <br /> Address pV1()A,is PIL�k& Q 1 City/State/Zip P­a'\r'�o Cor�a'S� (��r,oU tit <br /> Consultant/Sub-Contractor yrun}tc OnSu\t` bem-y , % License# /n� 11 Phone <br /> Address -3 4(} (L.� � �� . S H• It Ivo City/State/Zip K-c��c�a C-16,,, (A 94-62F <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH r ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) K HAMMER/DRIVEN DIA.OF BOREHOLE / r r ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> [FSOIL VAPOR PROBE =0 MUD ROTARY CASING THICKNESS7/( ��DO TYPE OF CASING: ❑STEEL ❑PVC Pj OTHER Te f-I o^ <br /> [ISOIL BORING [IPUSH POINT(GPI CPT) CONDUCTOR CASING '❑Yes ❑No Boring Dia: 0I Casing Dia: r z z Casing Depth: S'` <br /> ❑ INJECTION(Ay sparge Ozogel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. ❑AUGERS CIHOSE ❑PIPE <br /> ❑ OTHER —�—❑ OTHER: GROUT SEAL PUMPED? []Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WEWSOIL BORING IDs �J Vl" f ��� +yam GROUT SPECIFICATIONS p��t q��•o�� Grey� G j 4vi�-� GsiZ $ �l <br /> Nid{� 13 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feel <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 feel below surface or feel below surface if>3 feet <br /> COMMENTS: -e.M nCar C'� �{ I S - pec '-.If - of}� S", ,1, r' -W <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San J.�o`�aq/�u-�i'�n,�County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed / ,rt-s–•r i�7Z�S t/F w Title/Company <br /> Print Name ,A <br /> 1 <br /> Date_1 It I 1 .1 IS' <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: �/ti/� r/✓sn�-///Son / Date Issued: 1_7��/�s <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Pennll ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 290,3 ,5Z,3 (u.0/ewy i �.() 5it'0073799 <br /> Permit 2905' 3)3 $130x / �`/3D Z2 y7 Cl t .s' s/Z ro73$S9 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />