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4 } RECEIVED S A N .J O A Q U IN Environmental Health 96piqwt COUNTY ENVIRONMENTAL HEALTH DIA'ARTNIENT 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 Standards. �• q sta b Job Address Q y 7 W.. C 1�4�wwTE� WAy City/State/Zip S Tp�,�C 1'gN � Phone 'j,p� ` yVS $ Cross Street c 14AATtr wql TTNA N" D11�Vt APN 3414 PropertyOwMCCner* @Da1sLS SToGKTAN t L.L(- yv DA" t 1Ij9fAL11/^1 Phone Zo ` 41oS" 5$63 Address Ao. 80y, I52-P City/State/Zips TOC.r►Tord C4 95Z01 C-57 Contractor S/4 G.I E Dr,j1 CORP. License# 1 OSI ` to /l1D Phone q�`•3b3 9;5`S Address 33`°1 Fa zG:rill KD• . City/State/Zip Ron OrAwih Cl 'sly`L Consultant/Sub-Contractor O H11� QAV1� Lijensse#L* b &O it7 Phone\Z000 4147-1,0,016 Address 557 O\Aw City/State/Zip S'TocKtoN cA) CN$Z.IIY CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING �_K HOLLOW STEM BORING DEPTH BOLTED TRAFFIC BOX ❑STOVE PIPE NIA [:1EXTRACTION(VaporlWater) ElHAMMERIDRIVEN DIA.OF BOREHOLE E:1MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 46 A TYPE OF CASING: ❑STEEL ,PVC ElOTjfR [I SOIL BORING [I PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes)&No Boring Dia: * _Casing Dia: Z _Casing Depth: ❑ INJECTION(Air Scarce.Ozone/ El HAND AUGER GROUT SEAL DEPTH 03,00 TREMIE TYPE TO BE USED: Pq AUGERS ❑HOSE ❑PIPE ❑ OTHER OTHER: GROUT SEAL PUMPED? ❑Yes XNo (Note:Maximum Freefall Depth is 30 WELL/SOIL BORING IDs W GROUT SPECIFICATIONS por'rLA0 0 TYOt Or 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 ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS [I HOSE [-]PIPE /� E]MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: SLC IQuj&co A PPRojC0 UJ QM PI-40v VX-MID lbS j ZC) ZC 1 7 I hereby certify that I am authorized to complete this application and that the work will be done in accordance with IS Joaq'Ordinance Codes and Standards,and all other applicable California laws. Signed —74AghR Title/Company PAa�11LT AA.* VAGC#- I All-4 . 1Z . Print Name 7l M o J . CV E.1 I Af Date Q'I-i 5 — 2-0 15 D PARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information Q FA Name 0 e /'n FA Address l 0 S A/. /�. FA# �j�g68 PR#/ S � l� FA PE bo I VP Reviewed By �ork Plan Date ❑C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR , r COMMENTS/ N )TIONS: �`�t,� VJ,1 / A��✓ /l C 'V! 'D G�/y 1 D I WP TYPE PE S FEE IN90 AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit D 3i3 $152 x W Poo 399 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application