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SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT p/R��MENT
<br /> a: 1868 Hazelton Avenue, Stockton, CA 95205-6232 ERMIr/SE ES�TH
<br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.socehd.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
<br /> San Joaquin County Development Tide,
<br /> tle,Chapter 9-11155.3,and the San Joaquin County Well Standards.
<br /> Job Address D49Jr N. 9,rO L 4c, K . CitylState2lp,S/bG klbetC,� 95-2/9 Phone Zd9 75-Z-/000
<br /> Cross Street ik/C2Sf '3 �,/e- 9j • APN 066 05-036
<br /> Property Owner' 11,01Llard Me,, Phone 310 8(03- IS
<br /> Address 2550 ,' City/Statel2lp los Ude CA 9U Z �/
<br /> C-57 Contractor Fw;�,,,,,G, /,rl (e„l,,a / ASooc/b f�.&•License# 6959-?o Phone 43/!I6/o2-¢/n
<br /> Address 3011T„�•'•in prPk�mg 0(-,',!e City/Statel2lp 4,2 111 L4 Q6003
<br /> Consultant(Sub-Contractor PL-s Fe". .. .afa/ -r,, , License# Phone Y/5-)"2-1600
<br /> Address QPdwaod .B/w. ,St„'fL Zoo City/Statelzip Nov.16 C4 IL&gS
<br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits
<br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br /> III MONITORING _m" HOLLOW STEM BORING DEPTH 20-25')6$s❑BOLTED TRAFFIC BOX [3STOVE PIPE
<br /> ❑ EXTRACTION(Vapor(Water) ❑ HAMMERIDRIVEN DIA OF BOREHOLE $" ❑MULTIPLE CASINGS❑MULTFLEVEL WELL CASING DIA
<br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 21, TYPE OF CASING: ❑STEEL [I PVC ISI OTHER Prret,k ✓/ PI/C
<br /> E3 SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING [I Yes t,Zi Bodng Dia: Casing Dia: Casing Depth:
<br /> ❑ INJECTION IArsoama.oxooal M HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE [I PIPE
<br /> [I OTHER ❑ OTHER: GROUT SEAL PUMPED? [3 Yes 19 No (Note:Maximum Freefall Depth is 30 Ft) ,A7
<br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS 1, dr.fed 6a 6-,1e a/,orc. S.�A Hoek �7n .r1xr cowcC
<br /> cher, t'eme,1
<br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY)
<br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet
<br /> WELL IDs ❑PRESSURE GROUT To depth offeet below surface
<br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surface
<br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet
<br /> COMMENTS:
<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 laws.
<br /> Signed 2.-_-�- Title/Comp/any, ,,,,�� �{'
<br /> —
<br /> Print Name V, Date (p�z
<br /> � DEPARTMENT USE ONLY
<br /> Application Accepted By: D to Issued:
<br /> Grout Inspection By/Dates: 1 r - Irf
<br /> Destruction Inspection By/Dates:
<br /> Faclll ISite Information
<br /> FA Name _ �' FA Address L(t�� d•;� FAR -s�1�,�'�� � PR# D /�'
<br /> FA PE 6 L WP R viewed Byu 61110 Work Plan Date 4
<br /> G57 0C-57 Authorization for Other to Sign Permit FgQees Comp ❑Workers Comp Waiwr UEncroachnnertPermit ❑Access Agreement 0LeadAgenqAPxmvaI 42fARR
<br /> COMM ENTS/CONDITIONS:
<br /> SR TYPE I PE SC I FEE INFO AMT REMITTED1 CHECK#I RECV^D BY I DATE SERVICE REQQUEST# INVOICE#
<br /> 9
<br /> Permit O $139x 7 �� ob 7 ^/
<br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application
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