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P6117-W­11VA9`1 <br /> r <br /> SAN JOAQUIN COUNTY <br /> .e« <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> b�ll� <br /> 1868 Hazelton Avenue. Stockton, CA 95205-6232 <br /> �q..;... Telephone: (209) 468-3420 Fax:(209) 468-3433 Web: www.sicefid.coni <br /> �crFoa-�' <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 /( />t' /ivy L4* City/State/Zip ZG/I/9f ZJ Phone <br /> Cross Street GL QD Alyp kel- APN /11- 197,0-0/0-dd0 <br /> Property Owner' Phone <br /> Address 5-957 %.gO&AII✓D City/State/Zip pe/'�'f 144-jL•3 <br /> C-57 Contractor ` 0'0111"AJ License# �FSvbr Phone <br /> Address City/State/Zip '-I"rl'y A/'t'q 4s622� <br /> ConsultantlSub-Gent+ecWr j�/S .S.✓1-"4. License# Phone <br /> Address City/State/Zip ,2ulv,ll�l r��l 9fG18 <br /> — 7 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note. Offsite Bonngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaDv/Water) ❑ HAMMERrDRIVEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS IYPEOFCASING [I STEEL C3 PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP;CPT) CONDUCTOR CASING ❑Yes ❑No Bonng Dia: Casing Dia Casing Deptn. <br /> ❑ INJECTION(Arc srrarae.Ozone) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER _ ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note Maximum Freetall Depth is 30 Ft) <br /> WELD SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED y OVER-BORE DIAMETER of /tU inches to depth of TO feet <br /> WELL IDs 10PRESSURE GROUT To depth of 10 feet below surface <br /> GROUT SPECIFICATIONS S,(o q„/. /J;'o bS• I. Yi7,ln ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED JZ.YAUGERS ❑ OSI SE WPIPE° ®=MUSHROOM!CAP 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS:/hoNlfu12-1Ny ivP 1 G✓GADO w��"r c/ry o� ffuGk7�l /i'r��-✓!�- S <br /> I hereb✓✓y 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 laws. <br /> Signed min [iY1 /h4h�l Tille,Company QiQ jelzz lT)T g�l.l /�/G• <br /> Print Name � � �d�pti Date 7-Zq <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 /> FF.Name I FA Address I IFA# I I PR# <br /> FA PE I WP Reviewed By I Work Plan Date <br /> ❑C 57 ❑C-57 Auttgrization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Aoreemen+. ❑Leao Agency Approval ❑MPR <br /> COMMENTSICONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit $130 x <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />