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i ti ii 8 SAN M O N � � � 2(filtiriviron,nnotr W �6W))I h D64partment C t.;a ill 1 Y dVIR01\f�fEj�TAL H I PERf,1)TIsf jZV►{ 71f M1Ti��RVrc�S c ry i ,::'Li ,,..:•. 1.11 SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Fours Advance Notice Required For All Inspections Application Is hereby made to San Joaquin County for a permll to construct and/or Install the work described. ' This application Is'/made in compliance with San Joaquln County Development Title,Chapter 9.1115.3,and the Sari Joaquin County Well Standards, Job Address y R �ttfljP✓ t�''_�j/r/�/CltylStatelZlP4� � 7� Phone Cross Street 1 ✓ ,� J APN Property Own r' L $ 7y�1 sk4,xorl — --- — Phone Address _ lZ %JJ�U�ISEiO CIlylStale/21p �jge�nt � V t� C-57 Contractor � Phone �/3 Address �-p �W 4/a q T� CllylState/Zip^ Civ Aye N�9�5 Consultant/Sub-Contractor n Licensed Phond'P V G (y Address 3v jY)Cto &e de- I � alyrstat©rzip��.r}m�}a�(� 9S 3� CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsfWelis Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH Q BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VapodWeter) ❑ HAMMERMFIVEN DIA.OF BOREHOLE r ❑MULTIPLE CASINGS❑MULTI LEVEL WELL CASING DIA ❑SOILVAPOR PROBE ❑ MUD ROTARY CASING TH;C.KNFSS TYPE OF CASING:❑STEEL❑PVC❑ OTHER SOIL BORING _[ PUSH POINT(GP/DPT) CONDUCTOR CASING ❑Yes No Boring Die: Casing IXa: Casing Depth: INJECTION QLs v9a RlL� ❑ HANDAUGER GROUT SEAL DEPTH iREMETYPETOBEUSED:gAUGERS❑HOSE [I PIPE ❑OTHER ❑ OTHER: .- GROUT SEAL PUMPED? 17 Yes ❑No (Note:Maximum Freefall Depth Is 30 FQ WELUSOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECK ALI.THAT APP?Y) B WELLS TO BE DESTROYED _ _ ❑OVER-BORE DIAMETER of inches to depth of foet WELL IDs ❑PRESSURE GROUT To depth of__feel below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED E)AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet belmv surface or_ feet below surfn90 If>3 foot COMMENTS: Ltioroby certify ihl�t,l_ utho[Ize1Ito.complete;this application and that th.awork will t>e done Ipccofdance wdh- ?': a n Joatj ounty Ordinance Codas and`Standards;and all other appilcabls Californiaa laws. ' �i �^ Signed_ ty� Tltie/Company- .�*/1 �Ci r��i if WCL //// i Print Napl - Date 7'16•o20CY� —___.----_---- r _ DEPARTMENT USE ONLY Application Accepted By: Dale Issued: I I Grout Inspection By/Dates: Destruction Inspection By/Dates: FECIIiI /Sito Information FA Nome 1i ,� _ '.<, } FA Address I r� 1 - l �l 3 .1 tyvt i;- ?Jct t) F` �� L�(�7 S PRm pS`1 Z Itotl i FA PE WP Reviewed 8y Work Plan Data t ty CIC-57 ❑C-57Autharfxatlon for Olner to Slgn Permit ❑WOrkors Comp ❑Workers Camp Waiver ❑Eru-machmzni Pafmlt ❑Access Agreement ❑Lead Agency Approval ❑M{FR COMMENTS/CONDITIONS: � �. a �, '3>1-y6--&& i eL'vf" C.-Gw�.e .ov>rW {'ar_ WP TYPE PE SC FEE INFO AMT REMITTED CHEC{<# RECV D BY DATE WELL PERMIT# INVOICE# Permit S152x 1L' ' V J I5 I I L- y I'j - I 1L I % 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com EH D 29-0100-01-17 Site Millgalion We;I Pamel AppIcadon i ' �9 b3 4,S1� 3��8y X '��I 3 S Wo-4`�CV) i