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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />JUL 5 2017 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: vvww.sicehd.com <br />keisin <br />9........e..-i,•C:o <br />110h-% <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 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 />1C11 Arkl Covr4- City/State/Zip S4-0c K4dA(CA AS-2 06 <br />Wt54- CO (4-1 r W.Ci APN (63 -340 - 0) <br />Property Owner WkS4Cort IC Ark..i r h LL C.. <br />Address goS 11-1 141 C -1-ret-i.j sviii, 300 <br />C-57 Contractor C. ciS &k .Lt, Dri i I I 49) L. P. <br />Address 1000 0 V 1 V SI Lilt 4'4" <br />Consultant/Sub-Contractor qr A+ Envi ronrieri-Ill _....1 6Th TA il ,___License# <br />Address ty-27 ccipi-4-ctt si-isvi-ft (03 <br />Job Address <br />Cross Street <br />City/State/Zip Cororig/C/f/q2.9't 0 <br />Phone <br />Phone lo— 2Lio- 52Lig <br />R16-63Y— 110 <br />Isl.- 736- )'Pi <br />City/State/Zip 09 ici.(1/1eVCitVqq‘ I Z <br />License# ct3Vijo Phone <br />City/State/Zip WO" cfar f4610/CA Ai 56 ct i <br />Phone <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WEWBORING <br />MONITORING <br />EXTRACTION (VaporNVater) <br />El SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION ( Air Spam, Ozonel <br />OTHER <br />WELL/ SOIL BORING Ds <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Ereetall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br /># WELLS TO BE DESTROYED +WO OVER-BORE DIAMETER of inches to depth of feet N' <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 05.1PE 0 MUSHROOM CAP 0 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 />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed -Aar 4 VcietiPow Title/Company 6 eo to) I' Atli. vi fOnrkeipt i <br />Print ('lame Dt-ejo Vq s v2 Date 07/13/17 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br /> <br />Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />FA Name J ei) i Cacc_ FA Address i (:• Z.)1 _64,_ c.4- PM '-- 4-'47 It ) PR" 'S — EV Z51 <br />FA PE 7 '4 re WP Reviewed By 114" — Work Plan Date ', 6 ti —71 <br />U C-57 0 0-57 Authorization for Other to Sign Permit 0 Workers Comp El Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: a t s i ,,...t ht, (.2.t- cz,r,4,-)(- . _..:,a,i) a4- /-1 „., . <br />l' 1-'-'s41.A1- <br />Af1/4- it4Clik10"&t 1.- 114 6100/V, ,f. f r....w-e.c1-4,-- - <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit _ v.:, oz_ 31 '7) $139x 7 J 7-7 t/ 3'511 7/CA 00 7 -1 ci‘ 73 <br />4)41 L. A <br />Facility/Site Information !\(\''-' '4ir <br />4' 4,e <br />1'14 * %/sj \cit- <br />co-ic-etA <br />ck4A1-- {NI <br />s ,L ) 0 7 -) 7 L.__ <br />EHD 29-01 10-26-2015 <br /> <br />Site Mitigation Well Permit Application