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�� ,• SAN JOAQUIN COUNT3i RECEIVED <br /> ENVIRONMENTAL HEALTH DERI1FTIVIENT NOV 18 2015 <br /> 1868 Hazelton Avenue, Stockton, CA E'520!5-6232 ENIVIRGVM <br /> Telephone:(209) 468-3420 Fax: (209) 468-3433 .'IEb:www.sicehd.com PERMMjENTNTHEALTH <br /> SITE MITIGATION WELL & BORING PEPNII'r APPLICATION VICES <br /> For Wells and Borings Used for Contaminant Invest 3a[ti ons and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR::IV CATE ISSUED <br /> Applicailon is hereby made to San Joaquin County for a permit to conslrua id')r install the work described. <br /> This application is made in compliance with San Joaquin County Development Tale,Chapter ? 1 15.3,and the San Joaquin County Well Standards. <br /> Job Address ,emzcN*.o rwwr.fs-i, City/StateZP rxnrt, UW.0 Phone <br /> Cross Street I wy APN ,se.t3 <br /> Property Owner' a cwwuc,w awes. vafiwr Wmmnr (C,~Tm E.) Phone mast 3,a= <br /> Address ee+s aa.raa.x aom 7A s4 .ml- FW L �G[.>N 7 City/State/Zip s.o...,ne_d,ssers <br /> nw,aon <br /> C-57 Contractor uwo m„, 9r'rso - <br /> IS{or L(.nrBf G,r•iy License# eae3se _— Phone 19+613619335 <br /> Address IMFieya.w d Ctty/State/Zlp n.na„mm+.CJk 93 F42 <br /> Consultant/Sub-Contractor,+r� License# Phone I530l75s2.e. <br /> Address zen sn.nam sv..r City/State/Zip o..,.mann <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Acce u.Agreemehts or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH _❑SOL 'D"IV TIC BOX ❑STOVE PIPE <br /> O EXTRACTION(VapalwaW) ❑ HAMMERJDRIVEN DIA.OFBOREHOLE ❑MULIPLI C.ISINGS❑MULTI-LEVEL WELL CASING OIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE 0'.: :A AN: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes. ❑No "Di: ___Casing Dia: Casing Depth: <br /> ❑ INJECTION IAr Swme.0ian1 ❑ HAND AUGER GROUT SEAL DEPTH TREMIE I'PE TO BE USED ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:M:.:nu n Freelas Depth is 30 FB <br /> WEU/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METH('_):MqECK ALLTHAT APPLY) <br /> #WELLS TO BE DESTROYED + M OVER-BORE I „M-T:R of .5 inches to depth of 31 feet <br /> WELL IDs wMw-+ ❑PRESS JRE GROUT T:,detlh 3f feel bebw surface <br /> GROUT SPECIFICATIONS a.nrmm.m ❑EXPLOSIVES FI:m_ lo_feel below surface <br /> TREMIE TYPE TO BE USED ❑AU13E RS [:]HOSE M PIPE ❑MUSHFOOM CAP [.13 sett below surface or feel below surface if feet <br /> COMMENTS: <br /> 1 hereby certify that 1 am authorized to complete this application and that If a xorl:will be done in accordance with <br /> � SgGI fiance Codes and Standards,and all ott arupl:[feeble California laws. <br /> Signed f�r i���! ( Title/Colmp�any mwm <br /> PrinKi�me F OA,- - S\0.411✓ Date_ t��1r <br /> .��. <br /> JJ DEPARTMENT USE ONLY <br /> Application Accepted By: Ue'l �r p.�/�d/h / [:late Iss <br /> Grout Inspection By/Dates: .7e1 /�'E <br /> Destruction Inspection By/Dates <br /> Facility/Site Information <br /> FA Name FA Address ._L.Ati PR# <br /> FA PE WP Reviewed By _ _ Work PWn Oate <br /> ❑C-57 ❑C-57 AWpnzalion Ion Otw lo Sign Pemnl ❑Worker's Carp ❑Workers Carp Waiver ❑EnaU,mo <br /> oaPe mi ❑Access Agreement ❑Lead AgencyApproval ❑MFR <br /> COMMENTS/CONDITIONS: --' <br /> SR TYPE PE SC I FEE INFO JAMT FtEmrrmol CHECK#I RECV'D BY 'ET TIE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit '290 Z 313 13o X I g(30 $03S ✓7�i -- 5007376 3 <br /> EHD 29-01 6-23-2015 Site Afticiation Well Permit Application <br />