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SAN JOAQUIN COUNTY i RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> FEB 12 2016 <br /> • 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> �.9CiFGTelephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.socehd.com ENVIRONMENTAL HEALTH <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION PERMIT/sERVIcES <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 /> r <br /> Job Address $09S r� o N(onC.o r\d . citylstate/zip sloc-k+o: C14 75-2/7 Phone(Zoq)95-2 -loco <br /> Cross Street VtIPS)'�� S mt'le- kd, APN ��n0$ O S Z <br /> Property Owner* /TO WarA IAI6.nA P,. 1p Phone <br /> Address 2SStl ,ti e4on .., I05yeerdeS CA IOZII/� <br /> //�' V' ^^T S "1-�- 2Li City/StatelZip P <br /> C-57 Contractor C6g5("p d e 01 " 11r n c L P License# 735,110 . * Phone (V 6 3X- /l(e 9 <br /> Address 3000 p „I„t/1 + City/State/Zip Wesf S., s,dn � <br /> .. C�4r gT69/ <br /> Consultant/Sub-Contractor PFS License# Phone O <br /> Address I6'rZ Nava to A1,✓j. 5.., le loo cityistatelzip /Vo% fn CA 9Y)97 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELU13ORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20-ps+ ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE Z' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> )K SOIL BORING PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge.Omnel D HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 FI) <br /> WELU 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 here 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 I ws. <br /> Signed Title/Company?'tu .C'0N 460L,- 'T�•W JF6J1j14..0Al rk4&XZA .-. <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: " !/el Date Issued: _ Z/�Fh/�j <br /> Grout Inspection By/Dates: ivyG/ /6 <br /> , <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> EIC-57 ❑C-57 Authorizadon for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: C/�✓f �rir�j Gv/{•�r /?elG:<�6rt� CrQIsCGMe" _ ?�1& !Z°"""I <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REOU T# INVOICE# <br /> Work Plan Z9U 5 3 390 '� .J`�G /�Z�v(P C/1/ (' 5 i�OU7AI 24 <br /> Permit Z.y/r1` 3/j $130x 3 103-90 SZdad ClOrW 'ya007-'IZyZ <br /> p/1,1 wHr <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />