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re SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a i •` '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.secehd.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. Job Address / /n/ City/State/Zip SroGKjLw41e,4�9�1.d`� Phone Cross Street EL b0AD X6 r APN /3q-6Z'V -01p_OOD Property Owner' Phone Address S6s7 7-40(2µ/,4v City/State/Zip .f9rl Jo1P(z4 91123 C-57 Contractor 041"L-1 1'TeS7iNry, /WO. License# V,rl�'S�' Phone g2S.3/3 S8°Q Address 9'Se #0-we Ply City/State/Zip N!A/Z T4'✓e1 ConsultanU9ob-6entn►chTr Ake-'&S License# Phone 916 •f3GS 3�yy Address Srl/TP ? City/State/Zip�2G / Cy� CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING 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(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER 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) WELD SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED // OVER-BORE DIAMETER of J?-/0 inches to depth of 'rP feet WELL IDs PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS "b y/. #,,o S• ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED XAUGERS ❑HOSE PIE MUSHROOM CAP V3 feet below surface or feet below surface if>3 feet COMMENTS: Muv/-ru/ii-d Ne14 tPtAfQ/f 0w-Ji7P lif //p 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. Signed Title/Company / Eei/Yt�l1/�/ GyYJ/J N-S Print Na a Date 7 Zq-/V DEPARTMENT USE ONLY _-/ Application Accepted By: /��p�//C[iL//�/jo// Date Issued: /Z/Z�t/y rG�f.N�W T- Grout Inspection By/Dates: 'E��j Destruction Inspection By/Dates: ) Facilit /Site Information FA Name FA Address FA# c G 62.) PR# O05'</Z4 FA PE WP Reviewed By Work Plan Date ?e),-1 ❑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: /fie � k)-oVs Cc,5 kvr f L( bX �ffD /�e#i,"d,.-fF-! J6 AjO,.12cl f. Sec y Cin fa/Novel-� 7c� 1�'7 `+ �peg :,u` va 1�3 J% C�'CLr�le-fs.c �w G(�o�s7�ic��cNc ii rccG�:��s cc c��(t L3C�fe265 /Kc 7<sfdCk�fi if Jr reCe.tl�dA ode s7->1�WP l�h G�4 u.c'fzs� . ALF t SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit Z)�'�'- y/$130 X ^ ul�" I ZY vL r/Z 1 2/v /y Sig UG 7/D L, L� w' t4 Q /McIc IVW1 �?'/S ��c�J` /IL�•Lc'�;-e'-f"4, lc°if-, P(c'i.�SoC rU7t i !<'(,CIKaIC 1 ce,I ry et '��,�_J4.ST L✓ k, G,Hy tjclSY-✓Lj. EHD 29-01 6-23-2015 Site Mitigation Well Permit Application