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EDa P_M. SAN JOAQUIN COUNTY ty <br /> ? ENVIRONMENTAL HEALTH DEPARTMENT APR 632017 <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232R�MEN <br /> � E <br /> wrALN <br /> �' -:vok••p Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: ww.sicehd.com MIrjSERW S(ry <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 iS095 &'. Blanco Qct , City/State/Zip 57oc'k�y'j CA, 95'2/?Phone 20 952 '�oO° <br /> Cross StreetyeP'7 (8 APN 066O5-05-2- <br /> Property Owner' Howarcl We,'n/7 err Phone .(3/03(23 - 7-7;�5 <br /> Address 2.55-'0 (U�r"a_ TP on .Sv, 'l'e 28 Cltylstaterzip P'/0- l4eyAe5 64 QOz7y <br /> C-57 Contractor�-Tggg Nra/i�a .a Tes>' Ij. Tn C_. License# NS5-/(o5- Phone j9LS-)313 - 5-2 0 <br /> Address 950 City/State/Zip Ar4,ne2, CA 7Y553 <br /> Consultant(Sub-Contractor en✓,ionrnenhDrl ,C_. License# Phone 15 ed9-1600 <br /> Address 7665- Redworxl R/✓d Sj/-/e 2-003 city/statelzip SII Va'IV C.4 9y9Y5 <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsAVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING ❑ HOLLOW STEM BORING DEPTH y-73' )1"10'❑BOLTED TRAFFIC BOX [3 STOVEPIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERiDRMEN 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 /> 19 SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION verso m.omnei ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Fl) <br /> WELD 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_inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS ❑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 .I;unty Ordinance Codes and Standards,and all other applicable California laws. p _ <br /> Signed <br /> Title/Company 3er„or Sl1a fncin GPl//r5 J'Au u'✓n[n�r+l.�nc. <br /> Print Name &;p✓,0 S Date 3/ 3l// <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C57 Auhornfion for Other to Sign Permit ❑Workers Cornp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE I PE I SC I FEE INFO AMT REMITTED1 CHECK#I RECV•D BY I DATE I SERVICE REQUEST# INVOICE# <br /> Permit 1 $139 x <br /> EHD 2M1 10-26-2015 Site Mitigation Well Permit Application <br />