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SA6J0AQUIN Environmental H 99AWZQ COUNTY cgr. p Greotness grows here. NOV 21 2019 SITE MITIGATION WELL & BORING PERMIT APPLEIVA7AGMNTAL HEALTH For Wells and Borings Used for Contaminant Investigations and Rer�gdffiic AERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections q4-0 3 3�5— Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application ismade ±in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address _IM0I�?I l�P'ION4�i17- E 101AO City/StatelZip,�;tOO< ba/(�rJ[ �h�j� Phone Cross Street APN Property Owner* r LA Na tl,o/✓ I -)17 t CT - �ez. .SZ•V.t\wrk! ,,,, 0,S'f`o-CPU!,5�A Phone(� Address L',';%,-,^X.SI)E ZrJltCity/State/Zip C-57 Contractor_�/d W i��ILl.1N{�; l�� License# "�".�Q AXP WxO/Zo Phone (�"�•-SIJ�(-7)�'� Address �yc; QI C,l� CC��ti �'.�✓ City/State/ZipS;fU/�"!/ b% eA5�--tri Consultant/Sub-Contractor V AIV,i (,ero-oEGI's L( License# Phone Address"7L01 �,opj5 kp/ iV8 City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 4 MONITORING L ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS ,^_•t-0,•;n Cjtn my, TYPE OF CASING: ❑STEEL 14 PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 71 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft)41-% WELL/SOIL BORING IDs —GROUT SPECIFICATIONS CdE.4LR 1 �-� _ MKC� 6� JN►yl� 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 ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: CL) Lto-t.-SPk �-V, rv_jimnr'r\kkt! i_9-5;'N�) A-o (�OZ�! o� �t ✓Lf: �.��L :ji'�-r. 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. n Signed Title/company 9 /I??�� — / Si T,A/ Print Name G�j.priv }=0I7..jT-wer-J' Date EP MENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: I 2 Z Destruction Inspection By/Dates: Facilit /Site Information FA Name �� t� �' Address2g FA# /h O 2 S�R PR# l�( FA PE Q Sv WP Reviewed By V Work Plan Date ' V V► ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS:� M; 11.4 W o V" 5 v J .LjwtulS'�'�t tur•�-�" P('t�M i� OT WP TYPE PE SC FEE INFO A EMITTED CHECK# RECV'D BY DATE W RMIT# INVOICE# . Permit 0 $152 x 3 O C.C. �� Z( �1 ? 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 S 11 P Application