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101 <br /> 0 <br /> SQNttJOAQUIN Environmental Health Dep <br /> COUNTY— <br /> .......s,r, <br /> OUNTY—.mo.."r' Greatness Oro.. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <r� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 coIpliance with San Joaquin County Development Title,Chapter&1115.3,and�t�he Skarn Joaquin County Well Standards. <br /> Job Address , jr�� (�ti h f 1 City/State/Zip ��1C-t 104 -I-O phone <br /> Cross Street i IP(fI0VM✓'�i-c err APN 't7 70nr <br /> Property Owner• —✓nP'- :TQ fLq ,1' 1 1,k/vn� Corp 6(y, t2 Phone 510 6u3 <br /> Address L(5 t: ('�'h s'F r?, cityistaterzip�Arf t'6t(,1, ((4, 4 S3 2-6 <br /> C-57 Contractor ( C(OTC rf 1 UP7 License# -106 �S eIq PhoneS36(' 6 661 3600 <br /> Address 2 4- &A- 4' city/statelzip wZDJt tgPQ- q/8 c°ai6 <br /> Consultant/Sub-Contractor rt'A fLhCAJr <br /> 'f License# Phone SIO LIp &So <br /> Address ( ((.)L-( (,( { t/i'01 11s(.t �,� y- (> JC7 CltylState/Zip Ak1'IK)IC0q 4elq rl 2 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BodngsAlVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6-Z Y ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRNEN DIA OF BOREHOLE 2° ❑MULTIPLE CASINGS❑MULTREVEL WELL CASING DIA <br /> SOIL VAPOR PROBE _-b r--[I MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL El PVC ❑ OTHER <br /> SOIL BORING _6'_[j PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Spring Dia: Casing Dia:___Casing Depth: <br /> INJECTION I&Some.oyono ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS iOSE BIPIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes rl No INN.Maximum FreaWl Depth is 30 Ft� /� <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS_ vie-k GemCP�J <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Inches to depth of feet <br /> WELL IDs ❑PRESSUREGROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify tba4am authorized to complete this application and that the work will be done In accordance with <br /> .SSn Joa UIn CoLl�GrHinance Codes and Standards,and all other applicable California laws. <br /> Signed s ! -�� �� Title/Company 1'rT aif <br /> Print Name ("t, L r✓� ri ✓� Date 101'02 /1- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> 1 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facllll ISlte Inforanation <br /> FAName S.&�Je"V"^"' L"—"° FA Address ..-lam . ``Gv.�. C�k- FA# 00.2 )n , PR# i�sy 2S`La <br /> FA PE aASp WP Reviewed By L Work Plan Date 1 C) ( 3 1 <br /> ❑C57 Pf57AuthorbationlorothertoSignipanint DKorkerscomp ❑WmWsCanp WaKw ❑Enovschment Perdt ❑Aaeea Agreement ❑Lead AgencyAppraY <br /> COMMENTS/CONDITIONS: <br /> wPTyPrj PE I SC I FEE INFO JANIT REmrrTIEDj CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit 152X '3 1{Sl,>, nl"S(e'. j <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjoehd.com <br /> END 2401 ee-01-17 Site Mitigation Well Perrot Application <br /> W P --)f4o3 513 4 1sL� 3 $ LlSb outr� L-X i1110)1 j S(zou-7%7"to <br />