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SANJOAQUIN Environmental Health Department <br /> COUNTY f.R I I <br /> Grca(nrsi grows /w/ <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION/, /1 2021 <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEFD-NVIRONMENTAL HEALTFI <br /> 48 Hours Advance Notice Required For All InspectionsPERMIT/sERvlcl=s <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 Title, Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address a 391 87 `A W I 99 City/starelzip ACo1M PO ( CA 9 52ao Phone Wo g 36o7Cp/ <br /> Cross <br /> eet <br /> PropertyrOwner` RO)0Cr- A- ko ? KC\ APN Phone c90 I 3� p <br /> 9 _ 1 `fib <br /> Address 039167 Li l 99 citylstatelzipACaMPo ICA q saao <br /> C-57Contractor \IfA1\f1 DY'1IVanj License# agg383 Phone -2Oq 779 <br /> Address ?.0 . GO)( 4 .1 citylstatelzip CA IV, CAS <br /> ConsultantiSub-Contractor License# Phone <br /> Address City/Stalelzip <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: OBsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFICBO% []STOVEPIPE <br /> ❑ EXTRACTION(VaporlWater) ❑ HAMMEPoORNEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> 0 SOILBORING 17 PUSH POINT(GP/CPT) CONDUCTOR CASING 0Yes 0No eomp Dla Caskig Dia: CM4 Depth: <br /> ❑ INJECTION 0M soxae ozovi ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? [I Yes ❑No (Nola:Maximum Frmfall COO It 30 FQ <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED V0 Mj-1 ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs V1— V7 /S SG A- -7 U Aon-U 1O711a1g 69PRESSUREGROUT Todepthof3 feetbelowsudace llOt <br /> GROUT SPECIFICATIONS 61E%PLOSIVES From _lo 5 lest below surface <br /> TREMIE TYPE TO BE USED []AUGERS 19HOSE ®PIPE ®MUSHROOM CAP I&3 feet below surface or feet below surface if>3 feet <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 awa. <br /> Signed7—A /J '^ Title/Company y-, ce Pf-cs'I e n <br /> Tlle� F\a n �/ 8/.?Print Name T`c 1 S O Dale <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: ' <br /> Destruction Inspection By/Dates: <br /> Facilft /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE C v WP ReNewed By Work Plan Dale <br /> G57 G57ANMdratknforOthato Sign Pemca ❑Wolkefs Camp ❑Workers Camp Waver ❑Enuoacluem Permit ❑Access Agreement qfLea1A9exyA0MVaI MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED1 CHECK# I REc%rD BY DATE WELL PERMIT# INVOICE# <br /> Permit Ob 1317 $152x o v� 3 AI 33 <br /> l 1868 E- Hazelton Avenue I Stockton, California 952051 T 209 4 8-3420 1 F 209 464-0138 1 www.sicehd.com <br /> EHD 2"10"1-17 .4 MleesUm Well PermltAppllcbon <br />