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I <br /> I Avironmental Health Department <br /> C: l-1l/ I'd I <br /> SITE MITIGATION WELL & BORING PERMIT APPLICA110.142 II 202.1 <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEbNVlfR0NMENTAI. 1 IUAI.fI I <br /> 40 Hours Advance Notice Required For All Ins pectionsPFRM117sE1:Vl(,, .:; <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 Tllle,Chapter 9-1115.3.and the San Joaquin County Well Standards. <br /> Job Address Q 39` H-7 1-\w j 99 City/Stato/zIp PO 901 C A 9 52do Phone WO 9 3 6 <br /> 6 `1 — 9 1 Z) <br /> Cross Street ,�col\nc11) 4 R 7- APN <br /> Property Owner' ,0 C, A. Ki � \� Phone 0()q 3(.9 - 9 l ;� <br /> Address 939%-7 Nub `iq City/State/Zip AC(AMP6 / 0\ gSPRO <br /> C-67 Contractor \)ct 1\P I h f-l IV,n License# a`113 8 3 Phone �?O`I 3� `I ' � 77`I <br /> Address �.V . O ox 4 D CRy/Statelzip C-icl it V. C A q 563�1 <br /> ConsultanUSub-Contractor License# Phone <br /> Address City/Statelzip <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsile BoringslWells Require Access Agreements or Encroachment Perndls <br /> TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORNGDEPTH ❑BOLTED TRAFFICBOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapwi ter) G HAMMER/DRNEN DM,OF BOREHOLE ❑MULTIPLE CASINGS G MULTREVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPEOFCASING: OSTEEL GPVC O OTHER <br /> O SORGORING Q PUSH POINT(GP/CPT) CONOUCTORCASING QYes QNo Bodnp Dix CasNg Dix QiiInJOepN: <br /> b INJECTION ffiy xw.0,1 . G HANDAUGER GROUT SEAL DEPTH THEME TYPETO BE USED: GAUGERS ❑HOSE OPIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEALPUMPED? OYM ElNo (Netx Mazkn=FreefalDeplhb30FQ <br /> WELUSOILBORING IDs GROUTSPECIFICANONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLn <br /> #WELLS TO BE DESTROYED Lj() MW []OVER-BORE DIAMETER of Indies to depth of_feel <br /> WELL V 1.— V 7I E�I SC 2- -7 V i[�n-Q IOal 11�Jq®PRESSURE GROUT Todepthof�i feegtbeiowsudace '65 } o II01 <br /> GROUTSPECIFICATIONS �EXPLOBIVES FromS,.�lo feelbaim surface <br /> TREMIE TYPE TO BE USED [I AUGERS ®HOSE PIPE ®MUSHROOM CAP 3 feet below surface or feel below surface if>3 feel <br /> COMMENTS: <br /> I hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards, and all (other applicable California aws. <br /> Signed � 1 awm4 . Title/Company V 1 <br /> Print Name TJ 1e f V�a r c,1 w o n Date a/ a? <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Dale Issued: �� Z <br /> Grout Inspection By/Dates: ' <br /> Destruction Inspection By/Dates: FUL <br /> acllil /Site Information <br /> FA Name FAAddress FA# I PR# <br /> mot <br /> FA PE a v WP ReWawed By Work Plan Dale 1( � <br /> C57 C57Au0pl151brOU1toftg Pemet ❑WwkersC V ❑WOAere"W" 0EW0'*r---P'Wd ❑AocMAgreemenl Lead Ageroy MFR <br /> COMMENTSICONDITIONS: <br /> jwPTYPrj PE I SC FEE INFO AMT REMITTED CHECK# REOWD BY DATE WELL PERMIT# INVOICE# <br /> Permit 1?10-VI311 S162w D jf&,1> 3 (I I 3g95�13 _ <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 4 8-3420 I F 209 464-0138 1 www.sjcehd.coin <br /> EHD 19-01 0801-17 �1310 MLg.VOn Wal Pem1�APpr�aan <br />