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DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 2. <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE giTIpE <br />TYPE OFWELL)BORING <br />GKMONITORING <br />EXTRACTION (Vapor/Weter) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Alr Soros, °Sone) <br />OTHER <br />WELL/ SOIL BORINGiDs <br />NUMBER INSTALLATION TYPE <br /> 1511OLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> ID PUSH PORT (GP/ CPT) <br /> ID HAND AUGER <br />0 OTHER: <br />BORING DEPTH <br />DK OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED <br />GROUT SPECIFICATIONS <br />' <br />Boring Die: Casing Ola: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> Casing Depth: <br />WIPE <br />kVf /34 4- <br />s 0 Na (Note: Maxlmurn Freefall Depth Is 30 F1)7 etun4- 9 1%4 W +11 0/0 fe <br />CONSTRUCTION SPECIFICATIONS /' <br />EI,BULTE13 TRAFFIC Box CI STOVE PIPE <br />MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL Elk 0 OTHER <br />PESTRUC110 METHOD; (CHECK ALL THAT APPLY1 <br />ISII5VER-8ORE DiAMETER of P inches to depth of 2.S feet <br />PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 0 3 feet below surface or feet below surface If >3 feet <br />COMMENTS: <br />.h doaeltdtt brbance codes and.Stndards. and all otherappilcable: California laws,. <br />Signed Title/Company IWCL\ 1)1T(CkOr /C0t5COACI)is%I. <br />Print Name Date "hrt1? <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 ENV/RoNmEN <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wvvw.sicehd.com P RMIT/sE-,741.,./iEkri,/ <br />• <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />'1wCES <br /> <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 />Job Address 16 /1 Arrf Goal- <br />Address Li 35 <br />Property Owner' W•es4. core it Atfh.( Covr4-, L L C <br />0 4 So ilq Villtv. OAVt,Sv(fe q oo city/state/zip it OitIo/c/f/i 2 I 2 Z <br />Phone <br />C-57 Contractor C.,(1,41ilete, eri:I\ 1 VC)C,6 , L . P. <br />Address, L-t\,13 *Du.NuAA.1 nk . <br />Consultant/Sub-Contractor LIcense# Phone <br />Address City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offslte Borings/Wells Require Access Agreements or Encroachment PermIts <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Faci lit /Site Information <br />FA Name Ai2)) .K.:re--- FA Address -7) 2 n _ /6 ' IV 11 ( NIL _FM <br />e (*) i 3 P" C,),37-/ 2 ,C) Z • G i <br />FA PE <br />_ -Z-- E-1' CJ <br />WP Reviewed By Work Plan Date Ch6 b .-7 tittr <br />LIC-57 0 C.57 Authorization fa Other to sign Permit I:2 Worker's Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agedcy Approval 0MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC INFO .FEE AMT REMITTED CHECK* RECV'D BY DATE SERVICE REOUEST# INVOICE# <br />Permit 2}207_. 31 5 $139 x 174: `;,. 12: 7 7,:,, 7 i , <br />, .Z.--‘;/05 <br />EHD 29-01 08-01-16 <br />• <br />O77 0 <br />Site Mitigation Well Permit Application <br />CIty/Statealp 4-ac 1C 40 eV(A/q c206 Phone <br />Cross Street VeS+- ChI4r way APN 43-3qa-o3 <br />LIcense# ci -2)(2) k0 Phone gib - 63a— (IVI <br />City/State/Zip We.4,51- 13riarIVL1111-Int, CA CepC11 <br />Date Issued: p i/7 7 <br />glo-2,16-52.qc