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RikOECE,VE® SAN JOAQUIN COUNTY 2017 m: < ENVIRONMENTAL HEALTH DEPARTMENT ENV/RO r 1868 Hazelton Avenue, Stockton, CA 95205-6232 pERMMENrqL FALT •. �:e Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:wwwsicehd.com SERA ES y �I FON 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 fora permit to construct and/or install the work described. This application is made in compliance with (�San JoaquinCountyDevelopment Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 8095 N N"6o B/ano Rd, City/State2ip$--of'kfbnf CA 152/9 Phone 0 c152-/Uoo Cross Street We s 1� SS Ale /ZAAPN O j�;(o O SO 572 Property Owner' WY)/ ' p 1 Phone (S/o�363- ��•�$� Address $- O 1 T Y P/.Zs VeAe$ CA %z 9'y c � �• Cit /State/Zi C-57Contractor t v;mnr 4,j C".,n4ral /ic.r,ua/rsa S++c License# G 959 7,-0 Phone Address 3o11 7w,n Po-/m. City/State1Zipt*)6g C r %57003 Consultant/Sub-Contractor f&-5E,.•�e�mcn{al .rnc. License# -'I Phone (9/S�fr99-/600 Address 76657 Red✓c J /Vv,( S', /c 200 CitylStatelzip IV.,,f, C-4 L9yS CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsA'Vells Require Access Agreements or Encroachment Permits TYPE OF WELUBORINGUM ER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �rr�rr 19 MONITORING "- •9 HOLLOW STEM BORING DEPTH 0-23• A 3 W BOLTED TRAFFIC BOX [ISTOVE PIPE ❑ EXTRACTION(VaporfWaler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE $a- [IMULTIPLE CASINGS[IMULTI-LEVELWELL CASING DW [3SOIL VAPOR PROBE [IMUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [I PVC IN OTHER Pr-e Alc- ❑ SOIL BORING [IPUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yea E(No Boring Dia: Casing Dia: Cast Depth: e�pth: r ❑ INJECTION IAirsoarae.mmnet [IHANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [3 AUGERS [I HOSE [I PIPE ❑ OTHER [I OTHER: GROUT SEAL PUMPED? [I Yea; 19 No (Note:Maumum Freefall Depth is 30 Ft) WELD SOIL BORING IDs GROUT SPECIFICATIONSd 6Pn nr It all r nd /Inn✓l S ,�- 0 c �il/ AI 26ntm,< /A // / enere/J.ert DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) If 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 [I EXPLOSIVES 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 feel COMMENTS: 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 A�7 LfCy-,rz�� Title/Company5ynor .S1a6{ F�-,,,,,ee�AFS rn w.'cnmv�/c/ Lnc.. Print Name (—ct vin re;5S DateCnZ2-//7 EPARTMENT USE ONLY p /4 �7 Application Accepted By: Date Issued: W1/ / Grout Inspection By/Dates: -- 9 1 oN - - - (.- 77 Destruction Inspection By/Dates: d • — ri& / Facili! /Site Information FA Name PgL FA Address I O ro FA# u v&'1 2,71 PR# bS Q q FA PE O WP Reviewed By Work Plan Date 1-Z,y-/S /I_ _I 7 0657 Authwalion for Other to Sign Permit QtforkersComip ❑Workers Comp Waiver Encroachment Permit ❑Aaess Agreement Lead AgangAPOroval FR COMMENTS/CONDITIONS: SR TYPE I PE SC FEE INFO AMT/REMITTED CHECK# RECV'D BY / DATE SERVICE RE-QUEST# INVOICE# --d Permit ^OI $139x 4 �S� /J Z_ 6 j(I J0 7 7 /7 EHD 29-01 10-262015 Site Mitigation Well Permit Application