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oP4yl�•• SAN JOAQUIN COUNTY • `iEcel /1 >.:.�r.•..o . veo ENVIRONMENTAL HEALTH DEPARTMENT Al C 0`i� 2016 �: �`• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.comENPERM, ENTALH SITE MITIGATION WELL & BORING PERMIT APPLICATION TISERVICES 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. vV Job Address Z (r�s - CkAt t.{<r W^ , City/State/Zip�de Lfap 1,0 /S14hon Cross Street —T j 1 ;e-- L eta.i- APN I �3 3K3, 17 — Property 6 :,i 7 �/ Property Owner` Q d n A- y' r / Phone -f wn Address 't / Al-'e1r fT City/State2lp SrclekLA 9SZCl6 q C-57 ContractorQ, V W P t j I , p License# Q , Phone Zo9 4/ 77,00 Address p Q 6 L , CrGQ ,9r, // City/State/ZipQ 'TO i,�/} 95ZIr5 Consultant/Sub-Contractor �a eL Or T Ch• License# 23701-6, Phone-z-0-2Z-3g -4-Jr R Address 4 ai^ )—rte. , W<-sfi Cr. 57—e City/State/Zip__STctc fiavt Cr4 g5'zaj CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATI NS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH I 5t T- ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) D HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER .01�SOIL BORING I PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes�'No Boring Dia: Casing Die: Casing Depth: ❑ INJECTION(Air Sume.Omnel ❑ HANDAUGER GROUTSEALDEPTH (5,f T- TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑npTHER: GROUTSEAL PUMPED? ❑Yes ONo (Note:Maximum Fras"Depth Is 30 Ft)^ Q WELL)SOIL BORING IDs �2 ^ I, yl GROUT SPECIFICATIONS �JLf��4 ��M1�1�/ 9��'IPci�y'�IOA$' oT wacey- DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feel WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS C]EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 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/Jgaquin�Court Ordinance Codes and Standards,and all other applicable California laws, T Signed !--�z7 y[ - Tkle/Company A / GO ice f-5 r�e!!n Lr ore .r j I1% /c-('A' Pdnt Nameyy ' 0q, efO o , Date �/ 1 DEPARTMENT USE ONLY Application Accepted By: 1JL�'4 . n Date Issued: ��/p Grout Inspection By/Dates: /veil Destruction Inspection By/Dates: Facili Site Information FA Name FA Address FA# PR# FA PE I WP Reviewed By I Work Plan Date ❑C-57 57 Authwzatlon for Other to Sign Permit 014orkeesComp ❑Workefs C=P Waiver ❑Enamchment Permit ❑Access Agreement OL,6rd Agency Approval COM M ENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# Rill BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit 2905- 313 $130, rj9(j EHD 29-016-23-20,15 Site Mitigation Well Permit Application