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e -) SAN JOAQUIN COUNTY <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.slcehd.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 Count Deve_lopme T' e.Chapter 9-11 .3 and, a San,�o�quin countyWelt Standards. <br /> PP P q of MLS r�S 1,..GM �/�L,. I' T Cr <br /> Job Address fAl Ww.� City/Statttelzip pL -n. Yi20(ephone [,v I-'7�J - <br /> Cross Street �" , APN `3�•0-�- 1$3 — Q Z <br /> Property Owner' III hk)CL}�o GIs( ---� Phone `510-70, -M'o <br /> Address - t0/� y�n City/State/Zip s A ( (� '`- 1 L45 <br /> C-57 Contractor VI r� l.�V S�pC-L gs{EenBE# (Tjzz�� 5�1 }O Ph`o-nye TItOtO - }$ <br /> Address `% MS D'y� City/State/zip ys AI� <br /> ConsultantlSub-Contractor eV%CO,,, SO(V\rJ�S�• L• License# Phone Zl���SO"O, jj <br /> Address1?-5S A,-\-;s(f,f31VGa r- IS V rV City'state/Zip LOS I�eS 1 CA 010010 <br /> CONSTRUCTION WORK TO BE PERFORMED-'Note: Offsite BoringsM/elis Require Access Agreements orEncroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> EI MONITORING _0 HOLLOWSTEM BORING DEPTH2-0'-3.S ' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ E%TRAC¶ON(VaeorAYater) __0 HWMEFVDRIVEN DIA OF BOREHOLE "• •s 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> OVOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS N Ar TYPE OF CASNG'. 0 STEEL 0 PVC 0 OTHER <br /> SOIL BORING �@(PUSH POINT(GP/CPT) CONDUCTOR CASING 0 Yes-5kC Bonng Dia. Geeing Die: Casing Capin; <br /> ❑ INJECTIONINrsesoe droner __0 HANOAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED GAUGERS 0HOSE 0PIPE <br /> ❑ OTHER 0 OTHER GROUT SEAL PUMPED? 0 Yss 0 No (Note:Mm ovum Reeled Depth Is 30 FI) / 1 <br /> MILL/SOIL BORING IN SR— 1 1 3.(o GROUT SPECIFICATIONS rl eo-(- erets, M 4X{.4 ylla 5 2 H,w.-fr-s•..T[ <br /> -f'rei^ c J:!Vff<7 gjZkf er 301 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,t HE KALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 0 OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELL IDs <br /> GROUTS Q PRESSURE GROUT To depth of_feet below surface <br /> PECIFICATIONS <br /> TREMIE TYPE TO BE USED 0 A GERS Q HOSE Q PIPE Q EXPLOSIVES From to—feet below surface <br /> COMMENTS: �r� unCP,...e,w. ❑MUSHROOM CAP C1 3 feet below surface a feet below surface if>3 feet <br /> rr/` '}-, n ee of Writ M•`-Ice—'z.. <br /> I hereby certity that 1 am authorized to complete this application and that the work will be done In accordance with <br /> �,lo�aquln County Ordinance Codes and Standards,and all otherraapplicable California laws. <br /> Signed_ <br /> - TIUelCompany, y-)7c� <S:>10�lZyr-S <br /> Print Name1s�� <br /> Date It 4 1 S <br /> DEPARTME—EONLY <br /> Application Accepted By: 1. <br /> Grout Inspection By/Dates: Dale Issued: 3c,11 <br /> Destruction Inspection By/Dat <br /> Facllit /Site Information <br /> FA Name FA Address FA# PRO <br /> FA PE WP Rewewad By <br /> OC-57 0 C-57 AUdaizs0aa far Other toSign Permit 0 WateraP OWaksr <br /> Com Wok Plan Dale <br /> s Comp Waiver OEnnzoechmeat Pmmit DAarss Agreement OLwdAgency APPoNa1 OMFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE Sc FEE INFO AMT REMITTED C # RECCV'�Dr BY DATE SERVICE RREQUEST# INVOICE* <br /> Work Plan Z`ib3 S23 3'TC'- 39D.oa /LG � n 1 I$" xc 913-115 <br /> //Nc•^.' <br /> Permit Z,gOS 313 $130k 3 l-;lo <br /> ArlEx � F hor�K s <br /> EHO 29-01 623-2015 120422- l'UO Site Mitigation Well Permit Application <br /> 39u- rvs <br /> �pgCa/(/errYi Oarl�� Al r+41r`UAA5 a+J M"n; 7rK A�'Fu PTP <br /> 9 3 a C/r /.1-fj 9fZ o S <br />