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� t <br /> SAN JOAQUIN COUNTY <br /> 'i ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: K <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> r 6t � Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a pennit 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 �3� / /� VI �,�& klor, �?Iud City/State/zip Phone -- <br /> Cross Street APN 46 Z /50-3/ <br /> Property Ow er"yy 9, t /-W a m d✓1 Phone <br /> Address Od 6D 1� City/State/Zip <br /> C-57 Contractor ) License#C-1 fPhonega.• 3/a-&AO C <br /> Address 9 City/StatelZipi�/Q/T�i/GL Q�._ � <br /> ConsultanVSub-Cont�ra,c„tor � License# y r Phone <br /> ye cMPR ?farAddress 5 e �J. e <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ` ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS / TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> SOIL BORING :�� PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes B'No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(6!L§oM9_QuA ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 2rYes No (Note:Maximum Freetall Depth is 30 Ft) "Al <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS YCy�Gr�CI C'enieyr4 grutic%4 46-N /.l a <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED _❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs _❑PRESSURE GROUT To depthof feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIF TYPI=10 BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP (1 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> 1�aqAaquln County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company ,S WQL <br /> Print Name Date t t"1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: _ <br /> Destruction Inspection By/Dates: <br /> aclilty/Silly Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plait Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE j SERVICE REQUEST# INVOICE# <br /> Permit $139 x <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />