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CIJO'pSAN JOAQUIN COUNri 0ENVIRONMENTAL HEALTH DEP.'tFTIv1ENT <br /> 1868 Hazelton Avenue, Stockton, CA f+(i20:5-6232 <br /> !e Telephone: (209) 468-3420 Fax:(209) ,$68-3433 "/eb. www.sicehd.com <br /> ' <br /> SITE MITIGATION WELL 8 BORING PEFlhll'T APPLICATION <br /> For Wells and Borings Used for Contaminant Invest gtlti ons and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR.:N CATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to constm:la idor install the work described. <br /> This application is made in compliance with San Joaquin County Development'ritle.Chapter :-1'15 3,and the San Joaquin County Well Standards. <br /> Job Address CltylState2lp ixnR:.Gn:o Phone <br /> Cross Street n.m.ww APN +eo-woa3 <br /> Property Owner' eua oen uc..caaorceemma awan�m.ar lcan«v Tey Ewo.i --�—Phone (915)3243ae3 <br /> ro 1,lµ, 1 /vfJ 4 LP <br /> Address ea+s Eawcrosam IGr M(h 1 n 0 YZJ' City/State0p <br /> C-57 Contractor Aswwar.m,m.�i Troy+.; cA vza�z --- <br /> License# e.ews _ Phone (s+et3us3s <br /> Address 33e9flzyaaeR City/State/Zip R.,,e:_:o.a��rw raz <br /> Consultant/Sub-Contractor nroorr ..� License# _Phone (sw)iwz.ai <br /> Address 2ezr swn„m sue.i City/State/Zip o w.:.,es+e�— <br /> CONSTRUCTION WORK TO BE PERFORMED. 'Note: Offsite Borings/Wells Require Acca:;; A3n;emprnts or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICA-IONS <br /> E MONITORING 2 ® HOLLOW STEM BORING DEPTH 3i ❑BOC f 71 RAF FIC BOX 0 STOVE PIPE <br /> E] EXTRACTION NaporlWate) ❑ HAMMMRNEN DIA.OF BOREHOLE To--0_ MUL" LE CAiINGS❑MULTREVEL WELL CASING DIA<' <br /> O SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS _TYPE OF i A:INK; ❑STEEL 10 PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dc, ___Casing Du: Casing Dept' <br /> ❑ INJECTION lar Smme.Oxanel ❑ HAND AUGER GROUT SEAL DEPTH Ion TREMIE"r PE TC 3E USED: (NAUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes M No (Note:Ma,,our i F'relall Depth is 30 Ff <br /> WEW SOIL BORING IDs .Mw.+n.aMw-II GROUT SPECIFICATIONS�-in ae um.ry wd-roI <br /> am�mn,�xne.mm�n.v.�.a: Iasi..•°4'=n'vai <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METH ID: �cH ECKII ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED + N OVER-EORE DIfMI:TI:R of D.5 inches to depth of 31 feet <br /> WELL IDs shwa ❑PRESSURE GROUT T: fepth of i feet below surface <br /> GROUT SPECIFICATIONS n..am.,n ❑EXPLOSIVES F in_�to_feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS (3 HOSE ®PIPE ❑MUSHROOM CAP [; 31-at ie surface or feet below surface if>3 feet <br /> COMMENTS: .- <br /> I hereby certify that I am authorized to complete this application and that thn w Dfh well be done in accordance with <br /> San aln rrty Ordinance Codes and Standards,and all othi�•app(cable California laws. <br /> Signed Title/Com an wa-..,.a„-. a,a <br /> P YAa --- <br /> Pri amsti� �. le>•ot Date Nod •• 'I=� -� \ S <br /> i — <br /> DEPARTMENT USE ONLY ris <br /> Application Accepted By: /V✓L rZ`7Pr2�i2lf/n _haleIssu : <br /> Grout Inspection By/Dates: Ov/ /Zlg–/0115— <br /> Destruction Inspection By/Dates: <br /> leacifity/SlIp Information <br /> FA Name FA Address <br /> FA PE ..C_ PR# <br /> VYP Reviewed By Work Plan Date <br /> ❑C57 [I C57 AulhMxagon for Dlfer b Sign Permit ❑Warka's Camp ❑Waker'a Canp Waiter ❑Erexcechmd� 'a nil ❑ Agreement ❑Lead AgencyAppra al ❑MFR <br /> COMMENTS/CONDITIONS: --- <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY .gA TTi SERVICE REQUEST# INVOICE# <br /> Work Plan 2)03 523 39c 'T X038 CPT'iZ 1/-'1�115r 5P'067376F <br /> Permit 2901 1 31-j 130K Z__j SOfg00_(I 1(_ 3-1,r' S'k0 073 7 G I"' <br /> 2902 313 4•13& V 1030 0Vrf\ /(/a'/r,r 'R0()737 Z <br /> EHD 2"16-23-2015 <br />