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oaa`,log SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N < ° :'• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www.s*cehd.com 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 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 9-3 16 City/State/Zip T✓tt Cy (fe# JS3T6 Phone 20 13•F&729 Cross Street t e 1Q0IAPN Z 3 3 -V60 -O`Z p f� Property Owner* �, ./. L�Q"T'sz/ o" I. `` '' Phone`s/G�e��"� Address dt)4 2 C�S7g! 6ee-,4 J UacI% City/State/ZlpCdkf/�"/r��u/ WTyG C-57 Contractor License# C5-7 !1608'S— Phone `/i s 7roYl- Address .13/6 City/State/ZipciJcLt?/C�} ConsultanUSub-Contractor EIERs �! License# � � �G 1�3j Phone S/U 5 35 3�Z Address /0.3 0' � �Uc�c� Ff�y C,/t- %al]/� City/State/Zip_/yl/l ka! '; C4 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA,OF BOREHOLE Al ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER til SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes IN No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Nr sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 19 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDsa� GROUT SPECIFICATIONS /IC--1ta1- Gc11je.11 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [1AUGERS [IHOSE E]PIPE ❑MUSHROOM CAP El3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application"and that the work will be done in accordance with San Joaquin County ordinance Codes and Standards,,and all other applicable California laws. Signed Title/Company az e,,I,-X Print Name Date DEPARTMENT USE ONLY Application Accepted By: l�/_l�fO�I Date Issued: Grout Inspection By/Dates: !/ {.wo' C41 Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE I WP Reviewed By Work Plan Date ❑C•57 ❑C•57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: F'ot-n71 � �7');L ,�C.R►r�/61 /L/j//Sj C/ewe�r e� SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV-D BY DATE SERVICE REQUEST# INVOICE# Work Plan Z50S 5723 390 390 /o3ZCAW Si2007.3972 y" Permit 2)'05' 31-3 $130x j I`31b AS2 (W-IT S-944739 73 �Se 1S EHD 29-016-23-2015 Site Mitigation Well Permit Application