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- SANoJOQQUIN Environmental Heal��+ppp I� <br /> m —COUNTY— ;p ��ent <br /> "<rFoaN" Greatness grows here. RC((�; IED <br /> SITE MITIGATION WELL & BORING PERMIT APPLICmk--NTAL <br /> AUGQ ? 2017 <br /> For Wells and Borings Used for Contaminant Investigations and ReG03 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SER �ETN <br /> 48 Hours Advance Notice Rei <br /> ll i <br /> Application is hereby made to San Joaquin County for a permit todconnsttr construct For alnd/onssttallll tthe Ons wer described. <br /> This application is made in compliance With San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards, <br /> Job Address 25s4osouthscbone Road <br /> Cross Street Meusaln House PaI ChY/State/I T.,CA 553779709 <br /> Property Owns ,L APN 2o5saa3s Phone <br /> — <br /> cmomron � <br /> !t/Ir r141 i S / / f <br /> Address 25neos ns Irea d <br /> tGr 7� i,C-57 Contractor creg5omun9 Phone---------------- <br /> City/State/Zip 9s77rreoy, �ca <br /> Address <br /> 550 Haws Wase License# 485155 � <br /> Phone (525)313590- <br /> Consultant/Sub- City/State/Zip McNne;CA 94553 <br /> Contractor sianu,o consolgrp co,Po„1mn Ina. <br /> Address m5caalml Mausadae5o License# Amends Mages.P.G.#egos <br /> Phone P'6)s99-5992 <br /> CONSTRUCTION WORK TO BRFORMED:E PER City/State/Zip sea,emenm.CA 99581"583*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF— NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWS— T� <br /> ❑SOILVAORPREXTRACTION aporhyater) ❑ HAMMERIDRIVEN DAO BOREHOLE so ❑BOLTED TRAFFIC BOX <br /> BORING RPT-- <br /> ❑ SOILBORING ROBE ❑ MUD ROTARY ❑MULTIPLE CASINGS❑MDLT4 ❑STOVEPIPE <br /> © SOIL BORING 1z IM PUSH CONDU THICKNESS LEVELWELLCASINGDIA— <br /> ❑ INJECTION fa So n i POINT(GP/CPT) CONDUCTOR CASING TYPE OF CASING: ❑STEEL El PVC ❑ OTHER <br /> ❑ OTHER ❑ HANDAUGER GROUT SEAL DEPTH ❑Yes ❑No among D,a. Casing Dia: <br /> ❑ OTHER: TREMIE TYPE TO BE USED: ❑AUGERS ::Casing Deplh: <br /> WEW SOIL BORING IDs sa mrou5h 8-12 GROUT SEAL PUMPED? ❑yes El No (Note:Maximum Freefall De ❑HOSE ❑PIPE <br /> GROUT SPECIFICATIONS Phis 30 Ft) <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> #WELLS TO BE DESTROYED DESTRUCTION METHOD: CHECK ALL THAT APPLY) <br /> WELL IDs ❑OVER-BORE DIAMETER of.inch to depth of feet <br /> D ❑AUGERS ❑HOSE ❑PIPE <br /> GROUT SPECIFICATIONS [I PRESSURE GROUT To depth of <br /> �feet below surface <br /> TREMIE TYPE TO BE USEE3 EXPLOSIVES From_ _ <br /> COMMENTS: ❑MUSHROOM CAP t0 feet below surface <br /> ❑3 feet below surface or feet below surface if>3 feet <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 Amanda Magee •��--_----�-.......�..._. <br /> Print Name Amend.Magas m <br /> Title/Company Sea,Geo[ore,Slam..Conem9n9 cow,arnan mo. <br /> Date erne <br /> DEPARTMENTUSE ONLY <br /> ssIsss <br /> Application Accepted By: C <br /> Grout Inspection By/Date/ates: <br /> Date Issued: J <br /> i <br /> Destruction Inspection By <br /> Facllit /Site Information <br /> FA Name <br /> '—� FA Address ` 60 'I <br /> FA PE Fqp OC)Z,'7 / pNq <br /> Z WP Vexed By r� W <br /> Work Plan Date .L <br /> GE7 ❑ -57 DITIOhon29Oon for Other to Sign Permit Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit Accessggosemem ❑LeadA A mval <br /> COMMEN(T�SICONDITIONS:^,/ hC'iY_ � La pp FR <br /> �.J uArs U 1. r /_M" �L '0I CJC.Yww.., t/1-�r <br /> WP TYPE PE FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 2/0L15' 3� $152x3 -6 60 <br /> l� <br /> 1/jp868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 wwW.sjcehd.com <br /> H 68 09-01-17 <br /> ��3 y n nSite6Mitigason wel Permitgpphn en <br />