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IN SAN JOAQUIN COUNTY 0 RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT All? 05 2016 a s '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIR Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.socehd.com PE IRSEfAL NEgLTI{ RMIT/SERVIOES 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 r 2y /W r t-rLa l rt/ �/"A y City/State/Zip �tOG^�Urt CA 9S�Phoma (117 0oO5 Cross Street FIJI I fe, C ,e—y✓1 S APN !c/5 '3 36 017 '^ Property Owner' YI a'l C M Cn r Phon( W'g Address :31] S. Le.+ief �fi st tr�sC952o/ City/State/Zip y G n 5246 C-57 Contractor /n11// k./ Pr/I'll IA.q 1 License# -]2Q 909 Phonr�(7i 6 " 704 Address j80L /(//�� Com , 1)/�r ✓L�II City/StatelZlpSrOC�rUn44 I . 9'SZlS COnsultantIR-h•COntrector G4 f1 d r�Q l T!A Bc h Ar+� icense#. ZQ 26 ,t PhonCc Address ! 69 Gras W QST Cr. . SreT City/State/Zip . /pC rl-aq , 641 U04 I CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING --N---U,,,MBBERER,,,,,,(((INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS J3 MONITORING �J�6 HOLLOW STEM BORING DEPTH Z c T❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporWater) E� HAMMERIDRIVEN DIA.OF BOREHOLE �❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPEOFCASING: ❑STEELXPVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes o Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION Wr Soarue.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH S/ T TREMIE TYPE TO BE USED-O'AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes�Nuo (Note:Maximum Freefall Depth is 30 R! WELLI SOIL BORING IDs — GROUT SPECIFICATIONS I I j;'N 3 CQ M e-+'T f ,r— 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 C]EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ElAUGERS ❑HOSE ElPIPE ElMUSHROOM CAP EI3 feel below surface or feet below surface if>3 feel COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with ?_ San �Joaquiiq/County Ordinance Codes and Standards,and all other applicable California laws. 1 Signed .///.�f�i'Q C�JZ9�-"T— Tiue/Company.7Lot +.C�E'Lllag�ST-/�a�da/" /'Ti. Print Name_'' IT4-4 C 6 ok Date DEPARTMENT USE ONLY Application Accepted By: ��U/�L�/n/ �17� Date Issued: Grout Inspection By/Dates: A4,1is,",t 5L1$ Destruction Inspection 8y/Dates: Facili SI a Information FA Name FA Address FA# PR# FA PE WP Reviewed By I Work Plan Date ❑C-57 C57 Authonzation for Other to Sign Permit 0111orkeesCanp ❑Workees Cornp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency Approval FR COMM ENTSICONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2903 S-Z3 5lr %3,9e /-/'0 Permit 2901 30 $13OX '> X390 /ySG CyrjC EHD 29-01 6-23-2015 Site Mitigation Well Permit Application