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Y OP�UIN C� �� -� SA N J OAQ U I N Environmental Health Dept " f -COUNTY-- F �� reotness grows here. No� 0� O SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation �1, 1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made infcorrlpliance with San Joaquin County Development Title,Chapter�9--1115.3,and.thhe San Joaquin County Well Standards. Job Address �/V��J t ( I h f 9 City/State/Zip I{� /�I�� T JI•�3-Xhone Cross Street p �g, r-'it t� 0c APN '?-7 1�510-0� Property Owner* - � joyyl " Phone SID bc ; J b Address L(� �� (�� Sk $ City/State/Zip Tera C�r C�r� S1�-6 C-57 Contractor ( lie(ore r! I (i'Vlj License# Idef G1 Phone 53 666 3 690 Address Z Z fi .k l" City/State/Zip `^4�',D�I,yl'Ad/c{ Consultant/Sub-Contractor ,r License# 1 Phone ��O 6'tlp IVSo Address l (9�( y'iti{'� ({�( �,y !Z 6 ✓� City/State/Zip jAk--1'1K`/C/4 46/q e i e. 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 0- ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2r' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE _�j�❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC [I OTHER SOIL BORING _b'_❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: _ Casing Depth: INJECTION(Air Sparge.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS iOSEl PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes 1-1 No (Note Maximum Freetall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS_ Ij e-Ar C.e I1'I C hi 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 ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify t-bat4am authorized to complete this application and that the work will be done in accordance with ti. Sin"Joa uIn Co�rt]DAtf8lnance Codes-a Standards,and all other applicable California laws. Signed !i �� Title/Company r(T c. Print Name c 7 G�fel. TS r61 Date DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: l Facilit /site Information FA Name Swr J'O`WL&' ` � bZ�' FA Address � FA# PR# 1 �. ��,ni�'In S d0-2 1 �syz-3tt.� FA PE .fit 1c, WP Reviewed By �_ � Work Plan Date ❑G-57 57 Authorization for Other to Sign Permit 1216ers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval FR COMMENTS/CONDITIONS: WP TYPE PE SC I FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit . ` , $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application S 4- L--1X IQ)tllI1-1 S(?-0u-787') )