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A F R 2 61'10p <br /> SAN MO _kVIRO�'p Id"th El6pavlrnent <br /> C(1)Ui'� I y A E NTAL HEALTH <br /> PER1,11PSERVICES PcRi TIS6 W <br /> CESAt rN <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investlgations and Remediation <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 compliance with San Joaquin County Development Title,Chapter 9-1 115.3,and the San Joaquin County Well Standards <br /> q3c( Cityfs <br /> Job Address V407 rt- 9/U?/ tate/Zl P '/64,1 0* Phone <br /> Cross Street APN <br /> PropertyOwn <br /> Phone <br /> Address <br /> &A 1j5'6 0 City/State/Zip <br /> C-57 Contractor KP Lic Phone 9DY L/3 594) <br /> Address ?51'0 W//0 wea Clty/State/Zip y4n-4;1ei? <br /> Consultant/Sub-Contractor uoa3ike Oevirq -'Vnc License# Phon qG <br /> ' d'e 'S'id'-- -tP,5 — <br /> Address -5-0 lat'111 Citylstate/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLiBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [3 MONITORING 0 HOLLOW STEM BORING DEPTH [:]BOLTED TRAFFIC BOX El STOVE PIPE <br /> 0 EK-RACTION(VaporlWater) _[I HAMMEWDIRVEN DIA OF BOREHOLE El MULTIPLE CASINGS[]MULTI-LEVEL WELL CASING CIA <br /> El SOIL VAPOR PROBE Ej MUG ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL 0 PVC [I OTHER <br /> SOIL BORING M PUSH POINT(GP/CPT) CONDUCTOR CASING ffTe�NO Boring Die: —Casing Dia_Casing Depth: <br /> INJECTION iA,,tipw a o2um 0 HAND AUGER GROUT SEAL DEPTH 7RENiIETYPE TOBEUSED.gAUGER3 []HOSE OPIPE <br /> Cj OTHER L3 OTHER: GROUT SEAL PUMPED? 10 Yes Ll No (Note:Max1rnum Freafal Coo is 30 Fl) <br /> WELD SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED. DESTRUCTION METHOD:(CHECK td 1. THAT APPI,'e <br /> #WELLS TO BE DESTROYED E]OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs El PRESSURE GROUT To depth of__feet below surface <br /> GROUT SPECIFICATIONS E:1 EXPLOSIVES From--to -- feet below surface <br /> TREMIE TYPE TO BE USED F)AUGERS 0 HOSE El PIPE El MUSHROOM CAP [3 3 feet below surface or feet below surface If>3 feet <br /> COMMENTS: <br /> I hereby certify that I a�.yauthorlzed to complete this applIcallon and that the work will be done In accordance with <br /> In Joaq ounty Ordinance Codes and Standards,and all other appplicable Callfornla laws. <br /> Signed ------*',' Title/Company1r <br /> l' �(". <br /> �-16 -g <br /> Print Na <br /> _Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Dale Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates; <br /> Fuclllitv/Slia information <br /> FA Name FAAddress LA 31 (VI& f Id,I FAJY PR# ?–IW <br /> FA PE WP Reviewed By Work Plan Date r, <br /> CIC-57 OC-57Authorization for OLhorloSign Fera GftfkarsCornip OWorkers Comp Walver E]EncroachmealPermit ClAccess Agreerneril 0 Lead Agency Approval UOR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED I CIH!Ei�K—# RECV D BY )ATE I WELL IPERIMIT# INVOICE# <br /> Perrnit t 7 1$152 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-0106-01-17 Site MlItgation Wel Parnnil Applca-Jon <br /> J"' <br />