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M �,3 wz�S ,q. . a SAN .JOAQUIN COUNTY / RECEIVE® r. � ENVIRONMENTAL HEALTH DEPARTMENT ,APR 12 2011$ 0:- •.*1 -: 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTIi q•,.. .,..;;P% Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com PERMIPSERVIICES 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 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards Job Address 7 ///Qr of ��#jee-kt,t fyd City/State/Zip S�p��y1 Phone Cross Street _�pl l r(zW A�A �Yf �— APN ,/67_ /!;Q— 3/ Property Owner' All i 'x-31 ,.sydt"61n Phone Address DU.&A 5-cio ' City/State/zipk-d ,�!S �j6&0/ C-57 Contractor r License#GS r(��ts �' Phone?ax..•3/3^.Tj'0C Address 9 City/State/Zipoovl?--41 6 09 91`J7� ConsultanVSub-Contractor ,.4 License# IX)3g5 Phone ,?/(,, 6qe" 96 Address "I A .tCity/State/Zipfa(waM"-/y _ 9.Sy31S CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING _® HOLLOW STEM BORING DEPTH 3S ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE_ r—❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS yt q0 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER *-�16 �yr] PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes N No Boring Dia: Casing Dia: Casfng Depth: ❑ INJECTION(Air L4a-on Qz ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: I5 AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER:__ GROUT SEAL PUMPED? ❑Yes (51 No SNote:Maximum Freefall Depth is 30 Fl) WELU SOIL BORING IDs ftl A%n & MW-1 GROUT SPECIFICATIONS ,E✓ ar P r♦ &vA-.,4 jetlk ktne of 0 45- - i r DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of_ feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From -to feet below surface TREMIE TYPE TO BE USED ❑AUGERS []HOSE ❑PIPE ❑MUSHROOM CAP [:13 feet below surface or feet below surface if>3 feet COMMENTS: US- Z^C,1^� 15- e� L"ar ,ftvtr,4 ,ron -/V /f3 r. h..Ae r./o� /S' �?✓or !S` !V✓ e& r I hereby certify that I am auth 'zed o complete this application and that the work will be done In accordance with aquin Co Ordinance Codes and Standards,and all other applicable California laws.'' Signed < _ Title/Company �� Giin�`rJ� [✓�ne Print Name t td Date /0-Z7/ DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates _ Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FFA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMM ENTS/CONDITIONS: SR TYPE PE SC FEE INFO JAMT REMITTEDI CHECK# RECV'D BY I DATE SERVICE REQUEST# INVOICE# Permit $139 x EHD 29-01 10-26-2015 Site Mitigation Well Permit Application