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Address 3900 0/6/ I ,SWe,f/k/' City/State/Zip 14/0SY-SaC.frqb)e,ffq c,i51- _9 679/ Consultant/Sub-Contractor ,onlar fa/Y-A7-exhoioy;e6cense# .732 au' Phone (2 0602341— 05/g Address ag Pr4in Lie/57i- GP,} Set, Q/.2 City/State/Zip 5,;Y-190/6/L, C-4 r.5-2(26" CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING 0 HOLLOW STEM EXTRACTION (Vapor/Water) SOIL VAPOR PROBE NIA SOIL BORING 13 INJECTION lailt Some Ozone) 0 OTHER WE U SOIL BORING IDs I\ b ES RUCTION WORK TO BE PERFORMED: ? \‘ WELLS TO BE DESTROYED WELL IDs LIcense# Phone (f/f)(38—//6'1 El PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface o MUSHROOM CAP 0 3 feet below surface or feet below surfaced >3 feel TREMIE TYPE TO BE USED D AUGERS 0 HOSE 0 PIPE C-57 Contractor c sc, 6 11jha 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 48 Hours Advance Notice Required For All Inspections 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 Sta dards. Job Address -V 5 . grie, 1/09/ City/State/Zi / 61C-')/61'0S, Col 'i 5:49°P.Ene .2°47 33 7-005:5 Cross Street sr; ///' L eit61/5" Pi, APN /c3 34' (217 Property Owner* &prat? i c-,071,/e/5,47)-)ents ph poy)4-r—gc l Address g7 ? S. 7i--8it" 55z-ree City/State/Zip Ste3C/141'61/2) Oh f..542:-'1° HAMMER/DRIVEN MUD ROTARY pc PUSH POINT (GP/ CPT) HAND AUGER OTHER BORING DEPTH —o fl 0 BOLTED TRAFFIC BOX 0 STOVE PIPE DIA. OF BOREHOLE 2 .2- j..-41. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: GROUT SEAL DEPTH TREMIE TYPE TO BE USED: KAUGERS 0 HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes 54o (Note Maximum Freefall pepth s 30 Ft) GAO SPECIFICATIONS NVO-i C e)A---ey* (.9 v DESTRUCTION METHOD: (CHECK ALL THAT APPLY( OVER-BORE DIAMETER of inches to depth of feel Signed Print Name Title/Company Date John I ane PG#6795, Condor Earth June 8 ,20Th DE RTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information /1 Date Issued: SAN JOAQUIN Environmental Health Department COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. FA Name CO if yry%..2.1 ti t... t tin.% C.4-(...w. ,x..*-I col.A.' Al FA Address Fikk Ca-Z-3 3 84;1 PR# FA PE "/"1 0 WP Reviewed By %Jai L -y Work Plan Dale 2-- [Z-7 il 0 C-57 D'e-57 Authorization for Other to Sign Permit Ic4ortrer's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement [Read Agency Approval MFR COMMENTS/CONDITIONS:1c„j4,,....4pej-- t,s,. Q_AP-4,.,6 4...ryik--6.AK I 4s- ...V•14, 10 v r 1, "..,. b0:-L,,z, st.u„..4A he.. t .0 --C "O''''- V U'‘ Ao-frO” 4"-^",1 %-v-f------ Ai-set/ALIA C4..0-. ...4.-ce.A c. ) -e..,t ci-s- eve...at • WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit )_905 3 G $152x ii ViSio 1,541 L -)t. W is 00)173i-17j, 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 09-01-17 Site Mitigation Well Permit Application