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DECEIVED <br /> 1 . SAN JOAQUIN COUNTY MAR 31 2016 <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL HEALTH <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 PERMIT/SERVICES <br /> Telephone:(209) 468.3420 Fax:(209) 468-3433 Web: 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 /> Appiicalion is hereby made to San Joaquin County for a permit to Conslmtl 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 Welt Standards. <br /> Job Address �'.' Ls�V r;P�(�n�i(1� Ave- City/StotoRlp LOCA: n CA 952-40 Phan. "— <br /> Cross Street —10 Vol 5+rf 1– Ir Lhar/vY 5,- Uran APN C y SL) AC,a.1 1_ q p o <br /> Property OW'nar G-. Phone Z� I'd�3'6&1cl <br /> Address 2 ". } e Chy7statei t_Grti./� 15-2s <br /> C-67 Contractor � LlcenasA —117 /10 S Phone 9 ZS-313 <br /> Addmin 4b II cltyrstaump 1�1inFAe-z- Qy�53 <br /> ConaultanVSub-Contractor WrAler otx Cor\4�31-,kb:rgn ue.I+.N y-$3523 Phone �S/n—loll-2o4s <br /> Address 73Io6 WL(-YTer Sy. Dr. tee- Zy3 chy/StalelzIPCA94soT <br /> CONSTRUCTION WORK TO BE PERFORMED:-Note: ONeHe 6odngaMalls Require Access Agreements or Encroachment Pemllts <br /> TYPE OF WELLIBORINO NUMBER INSTALLATION TYPE CONSTRUCTION SPECIF -TIT-S <br /> O MONITORING _❑ HDLLOWSTEM SOWNG DEPTH . F�- �BOLIEDIMFFIC BOX 13 STOVE PIPE <br /> jKEXTRACTION(VO Mlea , -, (— O HWMER/DRIVEN D14,OF BOREHOLE I2.r' b MLTPLECASNOS 13 MULTHEV&WELL CAGING DU <br /> O SOL VAPOR PROBE 3 MLD ROTARY CASING THICKNESS ___ TYPE OFCASNG:ISMS.E3 PVC 13 OTHER <br /> O SOL BORNG _❑ PUSH POINT(GPI CPT) CONOUCTORCASNG ❑Yes®No Balrq Die: C6ring Die: Wkv Depth <br /> O INdECTIONIwrs .Oran,] _❑ RANDAUGER GROUTSEALDEPTH •r'C.'S• TNEMIETYPETOBE—USED AUGERS[I HOSE 13 PIPE <br /> O OTHER Bi'OTHERSOn� GROUTSEALPUMPEO as ONo lNob:Ala ovum feast In 1%30 FO <br /> WEWGOILBONNGIDS G :7 GROUP 3PECIFICATDN3 ern'F C'efMn�l.l)1Il�j�nd , s xa <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(CHECK ALL D:! ARRLYI <br /> A WELLS TO BE DESTROYED ❑OVER•BORE DIAMETER of—Inches to depth of_feet <br /> WELL IDs ❑PRESSURE GROUT To depth of_feetbebw surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES Fmm_to_leet below surface <br /> TREMIE TYPE TO BE USED ,{AUGERS HOSE PIPE MUSHROOM CAP 3 feet below sudme or feet below surface It>3 feet <br /> COMMENTS: (PSG L"r yu'h/o ��PG SF1i Plfr- aez X00:f l<AhrJ"Lica-CU-iL fle&J�Y(,--T` <br /> 1 hereby certify that I am authorized to compiete this epiew-s im.and that the work will be done In accordance with <br /> �-7 San Joequln County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed /�' Tide/CompanyR�- <br /> Pd a ) Q Dele 2n^i <br /> DEPARTMENT USE ONLY <br /> Applluflon Accepted By:_41 1.11�l� Date Issued: <br /> Grout Inspection BylDetes �/ y�6 .�'1Wcons�yuc�aC rm�Z wl"nQ�� PW is <br /> Destruction Inspection By/Date t: <br /> Faclll ISIte Information <br /> nN FAAddIeaB FAA PPA <br /> WP Ravi By WorkPlan Dab <br /> -67 ❑CS/Adhk"IorOOWID nPm* OWMkWSCMP OWakehOmpWeNer O6=%MWPawk OAsowAeaemenk ❑LSOA91MYAPPrOW ❑MFR <br /> S/CONDITIONS: <br /> SR TYPE PE 1 86 1 FEE INFO JAMT REMITTED CHECKS I RECV'D BY DATE SERVICE REOUESTA INVOICE# <br /> Work Plan 2y&3 S23 39G ;0"590 1 Z99Z �.P 3 3+ "I .�if'�7ySy <br /> Permit Z��% 313 i3oX / $ /3U Z99Z R 3/ / 3i*,V7 595 <br /> EHD 29-018-23-2015 Site Mitigation Well Pend Application <br />