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DLJ-sffe <br /> o.�°t`''F� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> •: 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: vvww.sicehd.com <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 /> Job Address / 7N City/State/Zip 115U4 Phone <br /> Cross Street 61- POAWP xl T APN /39—OZv -0/0—000 <br /> Property Owner' Phone <br /> Address 5807 -r'q P'k4/iW0 City/State/Zip Sp?rl jejP/�,d 41-123 <br /> C-57 Contractor s pRiLd/✓!J T(STiNry , /�G. License# �EK/G Phone <br /> Address c1Sb 6"Wit )24, y J City/State/Zip A41W Tr, '?; /Gy/`tS6 7.9 <br /> COnsu1tant13ub--6-&mtrvtt0T q.&4eY N.1-./ /A✓G• License# Phone 9/6 •$(i • 3zyy <br /> Address /dl (�//•/J///P /iGJP Cii S4 I-t- ;,Pk) City/State/Zip /Z',ey' C!F f 9S4,7e <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bonngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor,'Water) ❑ HAMMERDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia Casing Dia. Casing Depth <br /> ❑ INJECTION(Air Sparge.Ozone! ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Max mum Freefail Depth is 30 Ft) <br /> WELL)SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED // �OVER-BORE DIAMETER of J?-/O inches to depth of�feet <br /> WELL IDs •.PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS -b .r/. /{ O g s. L ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSFK PIE MUSHROOM CAP X3 feet below surface of feet below surface if>3 feet <br /> COMMENTS: w70Vfrv12-."ti'j i-eI4 Gp'-Afr/q 0,.-J77'0 Ar /(o NA/ i ". <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 taws. <br /> Signed Tide/Company6ry/��l17 i1/2GmJ[( li1_f•��y� <br /> Print Na e A11 of /��n/ Date 7-2q_111 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates. <br /> Facility/Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C 57 ❑C 57 Authorization for Other to Sign Permit ❑Worker's Comr ❑Worker's Comp Waiver ❑Encroachment Pemul ❑Access Agreement ❑Lead Agency Approval ❑WR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> I <br /> Work Plan <br /> Permit 130 x <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />