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City/State/Zip <br />LIcense# <br />City/State/Zip <br />, <br />t1cense# <br />City/State/Zip <br />ph...Par/Va.' 8.‘X <br />95--eaC . <br />Phone Saari!, 'ev <br />c <br />zti <br />kier. <br />Phone 12 092-239 — 05/F <br />Applicat on Accepted By <br />Grout Inspection By Dates <br />Destruction Inspection By Dates <br />Facility/Site Information <br />DEPARTMENT USE ONLY <br /> ios <br />- Date Issued: <br />RECEIVED <br />SAN JOAQUIN JUN 0 8_20IQ <br />Environmental Health Department <br />Lc..,LJNiY ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Job Address 2 t1/ 4Q'" 1/4/4 city/State21 ;- k)V) <br />Cross Street <br />Address 7? S Catalf 5i e* <br />C-57 Contractor 4,11e/ <br />Address 7 2OO p4l/61y, <br />Consultant/Sub-Contractor CM 40,r e 2tS noA <br />Address /gg 1".!:17.1C tv GP <br />- <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Of/site Borings/Wells Requ.re Access Agreements or Encroachment Permits <br />11673 <br />Property Owner* 64/ /rat <br />APN <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 />48 Hours Advance Notice Required For All Inspections <br />AppC:ation s hereby made to San Joaquin County for a permit to construct and or nstall the work described. <br />This application is made 'n compliance with San Joequ n County Development Title Chapter 9-1115.3 and the San Joaqu'n County Well Star dards <br />Phone .209)33 -7- o055 <br />TYPE OF WELL/BORING <br />PI MONITORING <br />0 EXTRACTION (VaporMater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />0 INJECTION (Air Scams, Ozone) <br />OTHER <br />WELLJ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11(' HOLLOW STEM BORING DEPTH BOLTED TRAFFIC BOX 0 STO E PIPE <br /> 0 HAMMER/DRIVEN CIA. OF BOREHOLE <br /> 0 MUD ROTARY CASING THICKNESS <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 <br />HAND AUGER GROUT SEAL DEPTH <br />0 OT.ER GROUT SEAL PUMPED? <br />2/11 S GROUT SPECIFICATIONS <br />s4' E) MULTIPLE CASINGS MU,TI-LEVEL WELL CASING DIA <br />TYPE OF CASING 0 STEELANC 0 OTHER <br />Boring Dia Casing Da: Casing Dec <br />TREMIE TYPE TO BE USED ,AUGERS 0 HOSE PIPE <br />(Note Mw,si. F4- cep is 30 Ft , ay/04, 5 of <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED DOVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPEC IFCATIONS ID EXPLOSNES From to feet below surface <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE 0 MUSHROOM CAP 0 3 feet be ow surface or feet below surfa .e f >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 <br />Print Name John Lane <br />Title/Companp PG#6795, Condor Earth <br />Date June 8, 2018 <br />FY-47P T E PE <br /> Sc <br />FEE INFO <br /> <br />AMT REMITTED CHECK# REM) BY DATE WELL PERMIT# INVOICE# <br />3)04 <br />FA Name Foo,ne H4-erkti C)A4wAcAth FA Address tzcts. w <br />T. FA# p,R# 1 °s(og-La <br />FA PE 0/ 14,9 0 WP Reviewed By <br />art„.57Authorintion for Other as Sign Permit arcorker's Comp Worker's Comp Wal El Encroachment Permit <br />Access Agreement Pi14.ed Agency Approve! fa0FR <br />Wort Plan Date .2 /41 / tif <br />COMMENTS/CONDMONS: <br />Permit 2,90 3I $152x 2.. j. ??0,q 1542 -y Ls (N r <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Parse t Appl cation <br />LAIP -'1 o 51.3 4 /SI" (4 ISNA 610 s g.47 0-19 z6"