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SAN J AQ N tal --U Uf Envirommenlea <br /> C()lli\il Y �, ✓ <br /> SITE MITIGATION WELL & BORING PERMIT APPLICA <br /> For Wells and Borings Used for Contaminant investigations and Remediation CES <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 Joaquln 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 4&1 C- / UV7/n �uf�t�/ k,,a _ IJ1�L_ City/State/Zip ­S�}ZjL_ io,n I�f� '?SGV& Phone <br /> Cross Street �a`t fA�C( APN <br /> Property Owner' '�U,Smoy-\ Phone <br /> Address .o. 35610 City/State/Zip_0 e I< r QCs (0 60 I <br /> C-57 Contractor S Y& - (I License# U( II31)2ID Picone Qp2S l3 5600 <br /> Address AO_- I-IOw e -J7o,J .___._. City/State/Zlip (lid X55 3 <br /> ConsuitantlSub-Contractor nl Mfr - C- License# _ 30Q jtfs Phone Q11. W6 Q6 <br /> Address es Harr-_.0—V _ L� C)tylState2ip t lr:itivitC4 t 5r`j3 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offslte BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )21.MONITORING �_�-HOLLOW STEM BORING DEPTH � [3'BOLTED TRAFFIC BOX I-]STOVEPIPE <br /> El EXTRACTION(Vapof/Water) ❑ HAMMERIDWVEN DIA.OF BOREHOLE E]MULTIPLECAS!NGS(]MULTI-LEVEL WELL CASING DIA <br /> El SOIL VAPOR PROBE [I MUD ROTARY CASING THICKNESS ctn U O TYPE OF CASING: ❑STEEL j$PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION IAT 6otinu OTOPai, ❑ HAND AUGER GROUT SEAL DEPTH TREMIE T"PE TO BE USED:jai AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? b Yes ❑No (Note:Maximum Freelall Depth is 30 FI) r <br /> WEWSO]LBORING IDs GROUT SPECIFICATIONS (-TepjI- Wf P1&O^d- uLAP'A� IS fo sVYruC� <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 feat <br /> WELL IDs ❑PRESSURE GROUT To depth of_ feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES -'rem to feet below surface <br /> TREMIE TYPE TO BE USED F1 AUGERS ❑HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMIENTS: <br /> I hereby certify that i am author(zed 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 laws. <br /> Signed / C� Title/Company ,, r� SCl P✓1 Y_(�_I�/I�-Z <br /> Print Name G, � , Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By! Date Issued: '-4 LV/ <br /> Grout Inspection BylDates; <br /> Destruction Inspection By/Dates: 1 <br /> Facillt !Silo Information <br /> FAName ,�tlt S�wt 510rR- FA Addressa>� p1�G, s�' FA# jf-+S1 PREF <br /> FA PE .�'j WP Reviewed By jr. VU Work Plan Date \(C, i <br /> EIC-57 ElC-57 Aulho"Lon for Other to Sign Permit ❑Worker's Comp ❑Workers Camp Waiver El Encroachment Permit [I Access Agreement []Lead Agency/Approval ❑MFR <br /> COMMENTSICONDITIONS: <br /> WP TYPET PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $fez X ICT", 4004 l t:I I k I Li f 0�X 1-1_1 9 <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHL)29-0 108-431-17 Site Mitigation Wel'Permit Applica'iol <br />