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o�°�'' c SAN JOAQUIN COUNTY _' —`�� ENVIRONMENTAL HEALTH DEPARTMENT : s I..:. 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.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 /!0 1fd jn y L4* City/State/Zip S>aG"VtV Z fl 74 51 Phone Cross Street j'L ftdo/,-7b f7/417 APN - C-t•7 of Y+ar Kt..N lZ. i+�(AJ�•� Property Owner* Phone Address 5-9-57 7-h D/LM/-V City/State/Zip I#je A f lqs- 3 C-57 Contractor 614� V/lijAq t-9 /rvy�i�/G. License# ZYSZ05- Phone 91s. 313•Ivo Address ED /#W/ ,"* City/State/Zip /111-irlW Alew/9S6�� Consultant/349@ 6 nHact r,,(y9OVIS O.S. ✓/'✓G• License# Phone 9/b•1gk- 31VCI Address /U/ G1//Kj1/,V / 6q& City/State/Zip 46tyV1111 /tA/ 9.rG78 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) ❑ HAMMERIDRIVEN 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 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) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ?i3 OVER-BORE DIAMETER of la inches to depth of TC> feet WELL IDs 54 PRESSURE GROUT To depth of 10 feet below surface GROUT SPECIFICATIONS S-(O#.q. 6S a• /.Pn^ly ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED UGERS ❑HOSE aPIPE' MUSHROOM CAP 3 feet below surface or feet below surface if>3 feet COMMENTS:/h Iivlrva'W✓✓d lura 1 t✓LAzi/f i-111-1 c/% of FfoGktrd /z4yl� 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 lain 0 Title/Company A501Pt�7 12nlA��l ArL4vl.( (��/�/G• Print Name ( ^� (pN Date 7 Zq I b DEPARTMENT USE ONLY Application Accepted By: V'clSSuet- vel •Sci✓t Date Issued: 77 911. Grout Inspection By/Dates: Al; Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# 1p02 3 PR# 10,57,//2 G FA PE WP Reviewed By I Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: LuC/(S f�, be V)��y� h mai,-eJ4cy1CC t 6-14D cypeot,.-I (elver SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit Z90 2 313 $130 x -J 35 FO � 592zc'07/C'3-S EHD 29-01 6-23-2015 Site Mitigation Well Permit Application