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vl SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> - Telephone:(209)468-3420 Fax:(209)4684433 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 Sen 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 Weft Standards. <br /> Job Addreas d00 N WnOgpe/( Ave. City/S1ateRip , thCl{ATAn cA CISZIS Phone coq• 4to5.3y5t <br /> Cross Street W(x9A;rWv%'00 APN 1433100 <br /> Propertyowner• SQX !12612. -Phone 99Q-t)44.3(ay3 <br /> Address 13sIS Sultan+yne Core. VI. City/Statemp Lhaxlel e NG dea9'k <br /> C-57 Contractor CAS=cke Dr;33LV1A ucensett Ot%j10 phone <br /> Address 120 Souk's 23rd' 913, __Chy/State0P SWAYrwYld LA 4443041 <br /> Conwitant/Sub•Contractor 1AWt3 AymeAA D..S 'rrYG. LicenseW Phan glto- II els54 <br /> Address 3301 t• at. Sv.;k CItyistaterLip SNCalo.tyMko CAL 9Sallp <br /> ATiN+ erft yzownoy <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note., Offsite 8mmlisAWelu Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIEORING NUMBER INSTALLATION TYPE CONSTRUCTION IFI Aja <br /> [] MONItORING _O HOLLOWSTDd BORING DEPTH 1 (�Oa O BOLTED TRArFICBOX []STOVEPIPE <br /> O EXTRACTION NaPmAVa(e) O HAI,DAEWRNEN OIA OF BOREHOLE a,.S-ftA, O MULTIPLE CASINGS O MULTNEVEL WELL CASINO OR <br /> O SOILVAIVRPROBE _O IAOD ROTARY CASiNGTHMESS Nft TYPEOFCASNG:[]STEEL OPVC(?POTHER Nk <br /> IM SOILBORING Ito ® PUSH PONT(GP/CPT) CONOUCTORCASNO OYN MNo SWrgda: C&*,9Ob: Cu4q Depth: <br /> [] INJECTION 006cra,Mw ❑ HANDAUGER GROUTSEALDEPTH le)ORWIl TREME TYPE TOSE USED,.®AUGERS[]HOSE[]PPE <br /> O OTHER Fr] OTHER:50"1Q GROUTSEALPUWED1 OYu D NoQlou:MaNnwn F,a4d Dephh7a Fq <br /> WELUSOILSORNODa Q•11..0.-IS d.-tq,tl.•is, R•W k-1 GRDursPECIFICATION3 Pari kCUA /rL YLPa} ceNKRn4' <br /> (C•Vd,k-ln, R'1o, 2.2�R.22, R-z3,�2w -zC;a•w,Q-1,+ <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECICALL THAT APPLY) <br /> SWELLS TO BE DESTROYED Ito DOVER-BORE DIAMETER of_inches to depth of—feet <br /> WELLIOS (L•IL -TVawv.At� 0-7} ®PRESSURE GROUT Todeplhof 14>0 feetbebwsudam <br /> GROUT SPECIFICATIONS rP cewrewk ❑EXPLOSIVES From_[a—feat below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS 0 HOSE ®PIPE MUSHROOM CAP t]3 feet below a rfm at .hfeetW��ow udace B>3 feel <br /> COMMENTS: foj3^ IM. WT1t. ba e O AM ir�JCL* a. (ekY�ec)Lo-a grod,ya_f* M AQV4;V% <br /> 0JDOJItC.3L.Ni sNr{AA VYt?0* UL"PJVTF Dv ) 2YIPi)Q (a'1'i0. LYn�. <br /> I hereby grey that I am authorized to complete this application and that the work will be done In accordance with <br /> Ben Jossgquuirt County Ordinance Codes and Standards,and all other applicable California laws, <br /> Signed�jT �. TMe/Company 5ie,o7 4_o%&Aee,^ RW 94//7/ <br /> Pnnt Name Z/YC e, R Oe►rHCZ:� Date / i' Guts rr3 / X0/6 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: '/'Ct�ff/L�<'— Date Issued: <br /> Gmul Inspection By/Dates: `,Y <br /> Destruction Inspection By/Dales: <br /> FacilltvISIle Infamation <br /> FAName 1 FAAddrms FAR I C)0 2352 PRY 054' /0J- <br /> FA I WP RevhNed By I lyeWofkPlanDele I c, <br /> ❑C47 5TC47AUWulkaAxOIhako,%nPtrafl UWwWrIeWw OWaddaCovIlAsrer 08wasAnadPamil OAoronAwwwK WKwdAiismyAwmal EHfFR <br /> COMMSICONDITIONS: t/fG rcwa rc p,pe. io cwtl)AC._ Srovt"�;�,�.I 60 <br /> (o� ccd rJr��Ovse/J %n ,IpIrJC(>o?K��/�,ri, <br /> SR TYPE PE I So I FEE INFO JAMT REMITTED1 CHECKS I RECV'D BY I DATE I SERVICE REQUESTS INVOICES <br /> Work Plan ZI3 152J -Y/7 -W7 87212 58007567$ <br /> Pernit 2905 1313 , X P87zlz S/eco-?S6�q <br /> Cµ e <br /> EHD 29-016-23-20115 Site Mitigation Well Pentyl Application <br />