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or-sere SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N: X •` '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*cehd.com 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. It Job Address 16 Am",/ kl, City/State/Zip �rfoj,4 7 v-leg/4S UV Phone Cross Street ,�j, pp,�iAjjp sT/J�g� APIN /3q-pyo -P/o-vivo 139-620 -43 Property Owner' Phone Address 4'V'5-7 TR-VIeI4/-IV City/State/Zip S;Ih/ /alt C-57 Contractor L/f7i /J/f,/(,tiiy f T�'ji�✓y f /'✓G. License# 11975/ Phone •-S'00"Address (o /kyw City/State/Zip A4AW7/,,/1Z /eA /lfik 79 Consultant/Sub-Can License# Phone 9�(i .��GS 3/y� Address 40/ 41j?X14 / Az/ CN/7/ 200—City/State/Zip 124JI01111P164Z9a7f/ CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Somme.Ozone) I—] HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL]SOIL BORING IDs GROUT SPECIFICATIONS 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 N1W O-PRESSURE GROUT To depth of rP feet below surface GROUT SPECIFICATIONS /• o b • rWw ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE PI N-MUSHROOM CAP El 3 feet below surface or feet below surface if>3 feet COMMENTS: 1niN1rVV1 k4/1 /S GoygyBO OGrPre, a✓ // 6 (.rj//o�✓St/�/. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. SignedTitle/Company j!ftpL,7 ZV! IV Z99,,L, yj/J4 71 Print Name �'T• � �p,� Date DEPARTMENT USE ONLY Application Accepted By: — Date Issued: �y, Y Grout Inspection By/Dates: 22 � Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# ('CZ' 3 PR# GCS Z� FA PE WP Reviewed By I Work Plan Date i,.�i14; ' ❑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 COMMENTS/CONDITIONS: v2SY�vy 41e&Ajr4 qvved�, Erb /yiXer /G.4,6-WZ-6/ N SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan , �i 7 Permit Zr��'�- j(� $130 x y�v r'JyZZ �/Li�� /L 2Y��l/ ��U(7C fU 3-3' EHD 29-01 6-23-2015 Site Mitigation Well Permit Application