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xo,.P4.. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N. 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.socehd.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 8095 )1t110 s[Onc o /Zd- City/State/Zip STo(-khn CA yS2/9 Phone 209 952-1000 Cross Street VAS o('IL IZ d• APN 046057030 Property Owner' {}owardua Phone ?- -7- 5- Pals- Address ZSS/C+ ,/,'� l!1TGro.� Sup ft Z� CltylState/zip Imes- VerJeS Citi 9ozn C-57 Contractor ( A Ori I 1j"Al L. h _License# 1,311/0 Phone 9/6 38- 1169 Address 3006 D 1 ) fk City/State/Zip14Cst Scro,me/n&7 �.A, 7no ConsultantlSub-Contractor P65 =r_. License# Phone (yr S) ?77-/600 Address )G'9?- /lova fb a l jcl Svr'fie. /oo City/State/Zip Nov do 64 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH W- Z5, ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporWater) EI HAMMER/DRIVEN DIA.OF BOREHOLE Z" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING X19 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.oronel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 FI) WELL/SOIL BORING IDs 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 E]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 feet COMMENTS: I hereb ify that I am authorized to complete this application and that the work will be done in accordance with Sa Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed \\ Title/Compan'y/�a[.tnf�Po� G6axa1�/PE$ FNJrLONwM6•WT/JI- Print Name A 5 U Date '7' !l�(y ,y/ DEPARTMENT USE ONLY Application Accepted By: y//g� -(� i�srJ�'j Date Issued: Grout Inspection By/Dates: &/ilFL�S(/r �! Destruction Inspection By/Dates: Facilit /Site Information FAName FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C57 ❑C57 Authadnbon for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval []MFR COMMENTS/CONDITIONS: Cdv,E .6efr 71 w,44 /ICG I"-IAlo, CO.Gu.(.[c.7 SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 7 Permit ZXr 3(73 $130x 3 Skc4OMZl(8._ EHD 29-016-23-2015 Site Mitigation Well Permit Application