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o,a�Ifr. • SAN JOAQUIN COUNTY 0 RECEIVED IVED ENVIRONMENTAL HEALTH DEPARTMENT APR 05 2016 Q: 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRO Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.smcohd.com pERMITSERO�ES�TN 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 9-111/5.3,and the SanJoaquinCounty Well Standards. L Job Address �II' rL e.�;s 0 .,300 -&M I-r {�ifem City/State/Zip SreC bran C f�j5y1 Phone 6 o l' et4plic,.ble Cross Street r 7-.e W�, APN � ; "I"./ ��Nlr 1'C j/„ 7-01137- 11q9 Property Owner` 'r., b *pCZrrP✓t Phone Z. Address 5 IV'n • - Votes d 0 5 !e I City/State/Zip 5lacl,r0AC14 932"2 C-57 Contractor tA/ f `) License# 7 Eol d Phone24"161 7;N1 .911(3 Address // / e � Z45 Consultant/Sub-Contractor fOACof eA -0 C'4 Ao JLicense# A 2 '73 ZD Z� Phonee70-VZi(-1-65/5 Address a &SAL "ITG-, Sir L City/State/Zip 4/- 00 U-21046 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaparMater) O HAMMER/DRIVEN DIA.OF BOREHOLE 1G Cl MULTIPLE CASINGS❑MULTH.EVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ,r El MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL 11 PVC ❑ OTHER 9S01L BORING �r PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes:i N Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(A,Soarae,Omnel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:M,axi^}Urn Freefall Depth is 30 Ft) WEW SOIL BORING IDs B 3I GROUT SPECIFICATIONS q fl 1)2 e,,[i G n�fOA�re'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 El EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ElHOSE C1PIPE ❑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 Jo�aquin/Cpuunn - Ordinance Codes and Standards,and all other applicable California laws. Signed '/ J�C�I.7 ->•Xit�6s Title/Company VGA 5T/COAdd Print Name r/I Cao < Date ,,��// DEPARTMENT USE ONLY Application Accepted By: /Vy1111�// ; OI1 Date Issued: Grout Inspection By/Dates: /J/..G/ i��? 5/a//� �''^'S ro�l�'-� to a.5�1ua.X r� Destruction Inspection By/Dates: �^'�w�/�c�er, S'co�.r• y0 Cr�b�C o � Facilit /Site Information FA Name FA Address FA# PRN FA PE WP Renewed By lWorkPlanDate ❑C-57 C57 Authonution for Other to Sign Permit Q-Waees Camp ❑Workers Comp Waive Fnaroadiment Peonil ❑Aocess Agreement Bfead Agency Approval EKFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTEDLCHCK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan /IPermit 2905 -3(3 sl30x 3 Jl 390 � alto / /� J' 0U 7AI 9 EHD 29-016-23-2015 Site Mitigation Well Permit Application