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0 0 SAN JOAQUIN COUNTY INV -� ENVIRONMENTAL HEALTH DEPARTMENT ly. < 1868 Hazelton Avenue, Stockton, CA 95205-6232 `C`d�IFORa Telephone(209) 468-3420 Fax:(209) 468-3433 Web:wwwsjcehd.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 lSb1 �, ; City/State/zip FcY-�� CA2s�hone t Cross Street �)r v� t,llFr1 j„ tyc{�,ys �Pa ;APN PropertyOwner' �r>r,1 �rn.v,� ;� Phoned�t- Address 21Se3U1 E. Nicy+wa l �'Z{7 t� City/State/Zip EScmi,(oni CA C-57 Contractor �c.irGnck Gt.1�iv., L C License# 1,7393 Phone Address _1 `G Ga E, �, G •� City/State/Zip Wano,624r t'!", Consultant/Sub-Contractor KZ ^ee)1 1,—Lta �-S f or%S.V I!ti^-I,;License# Phone Address �,?ttj E__� v.n I Sw'�t City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 MONITORING Z HOLLOW STEM BORING DEPTH —t06�4- ❑BOLTED TRAFFIC BOX STOVE PIPE El EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ;nc 1, ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Se (, TYPE OF CASING ❑STEEL�I PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes No Boring Dia: Casing Dia: xi A. Casing Depth: NP, ❑ INJECTION(Ax Spa oa 016n9t ❑ HAND AUGER GROUT SEAL DEPTH -&SIC-f TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE 0 PIPE ❑ OTHER ❑ OTHER: __ GROUT SEAL PUMPED? X Yes ❑No (Note:Maximum Freetall Depth is 30 Ft) WELL/SOIL BORING IDs f— -P t K, r^(,0- P2_ 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 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS _[IEXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with /' SanpJoaq`uin County Ordinance Codes and Standards,and all other applicable Cali rrnnia laws. Signed 7-l / \ 1 - _ Title/Company �'1�c�Ir�r ctr.Pv�vt� .��<°Kk S C oYtSl�ian5 Print Name Date DEPARTMENT USE ONLY Application Accepted By: Date Issued: '41,7, 1 Grout Inspection By/pates: Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address '_'t �l�DK." i 2�3 FA# t Lo'c csr- f7C!�21 3 C( PR# FA PE �,� WP Reviewed By `y`- Work Plan Date FIC-57 ❑0-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permil ❑Access Agreement [I Lead Agency Approval [3 MFR COMMENTS/CONDITIONS: - ----- SR TYPE PE I SC FEE INFO AMT REMITTED1 CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit -31 $139 x 2 -L7 0 f 3b0ytiI `i1,,. - I A 1 I b 914i3q x 3 41 f 33(vog,j q jIz fit yleoo�(77�Oo EHD 29-01 10-26-2015 Site Mitigation Well Permit Application