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Aa`''" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> • �q..; .:.•�P. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com <br /> \rFOR� <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 721 East Charter Way City/State/ZipStockton, CA, 95206 Phone 209-463-0751 <br /> Cross Street Stanislaus Street APN 147-343-10 <br /> Property Owner'' Keu Sun or Mei Au 'i t Phone 209-467-0305 <br /> Address 721 East Charter Way City/State/Zip Stockton, CA, 95206 <br /> C-57 Contractor All Well Abandonment License# 848359 Phone 916-363-9355 <br /> Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova, CA, 95742 <br /> Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING O Yes ❑No Boring Dia: Casing Dia Casing Depth: <br /> ❑ INJECTION(Airsparga Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS❑HOSE ❑PIPE <br /> ❑ OTHER O OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum F(eefall Depth is 30 Ft) <br /> WELD SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 N OVER-BORE DIAMETER of a inches to depth of '9 feet <br /> WELL IDs s'r-4 ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feel 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: See work plan for additional details; <br /> I}ereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> / San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed AI TitWCompany Project Geologist/AGE <br /> Print Name Da 1 Villanueva Date 10/27/2015 <br /> � DEPARTMENT USE ONLY <br /> Application Accepted By: /(//�',l� !`T��ZC�L'ifzi7 Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA#, PR# <br /> FA PE I I WP Reviewed By Work Plan Dale <br /> CIC-57 ❑G57 Authorization for Olher to Sign Permit ❑Nrorkers Comp ❑WOrt:er5 Comp Waiver ❑Encroachment Pem9t ❑Access Agreement ❑Lead Agency Approyal ❑MFR <br /> COMME NTSICON DITIONS: <br /> SR TYPE PE SC FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan Z <br /> Permit is j I > <br /> $130 x f 3 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />