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SAN J OAQ U I N Environmental Health Department <br /> I ," COUNTY ft Ck'�CQ p,� <br /> t:. reatness rlre�ws hers. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICA9 9 iAf <br /> NOP p� <br /> For Wells and Borings Used for Contaminant Investigations and RemedT <br /> 44 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ry <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct 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 Well Standards. <br /> Job Address FYFFO AVE City/State/Zip SFych"�_)64Phone ZO' yyG'OZyo <br /> Cross Street NAv y 01z1�F APN /G Z O 3C,0 ,Lz <br /> Property Owner* PoR•T' pF ST oGhroA1 // Phone ZOy yYG. UZSl <br /> Address ZZ01 W WASHIA.ACTbA­' S7. City/State/Zip 570G1tT6!v 64 ,/ySZo3 2 <br /> C-57 Contractor V f W D A-TL LS.uG License# -72 d ?64/ Phone z O7 VC f ? 0 <br /> Address 1133 i3LAGA_H1yASTytiTof City/State/Zip 6 QLT Cao 9SC3Z <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings ells ire A es`s Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPE IF ATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH MO*,60 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREL — �' / El MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA <br /> El SOIL VAPOR PROBE MUD ROTARY CASING HICKNEHOS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> SOIL BORING G PUSH POINT(GP/CPT) CONDUC RC NG ❑Yes No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soerae.Ozone) ❑ HAND AUGER GROUTS PTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL UMPE ? ❑ s ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs / 3 Z_ [3J' 19 y GIT j GROUT SPECI <br /> Z <br /> DESTRUCTION WORK TO BE PERFORMED: STRUCTION METHOD: CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs F1PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE'APIPE4E] <br /> MUSHROOM CAP [_13 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> 1/ <br /> I hereby certify that I am authorized to co plete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinanc Codes and Standards,and all other applicable California laws. <br /> Signed ✓ Title/Company 54FA-�.Tv4 �X.)6'— _)'e!E/\�wAt�AZ�"ffyNG f AsroL <br /> Print Name �Z�g eA:, LA t.,' e,z- Date dL7- 20 /06 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />