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Sep. 30. 2015 3:02PM San Joaquin County No. 1371 P. 2 <br /> r SAN JOAQUIN COUNTY <br /> • r` " ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1668 Hazelton Avenue,Stockton, CA 95205-6232 <br /> •. Telephone:(209)468-3420 Fax:(209)4683433 Web:www.sLcehd.com <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigatlons and Remediation <br /> N!2d-REFUNDABLE PERMIT ggElEgS 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquln County fora permit to construct and/or install the worst described. <br /> This application is-made In compliance with San Joaquin County D$velopment Tale,Chapter 9-9115.3,and the San Joaquin County Well Standards. <br /> Job Address 7 t: GSJ CityfStatp G hone '�f `�1( <br /> CrossStraet U AFN 1 `I�u1�c)Z �ieP{j,.-I� <br /> Property Owned` WhIllyle Ph <br /> Address !�t CltylstatelI Zip liL , �" Cs4 `vim <br /> C-57 Contractor (/�. 11111 Cleanse# q Phone � •� 13"�8t'�7 <br /> Address � '• _ CitylS4ata p yrt/r y' r �a <br /> ConsuitantlSub-Contractor License# Ph nee <br /> Address VG[ 14e,�t} Cityistatewp <br /> CONSTRUCTION WORK TO BE PERFORMED:*Not®: Offsite BodngsPelts Require Access Agreements or Encroachment Permits <br /> TYPEOFWELUBORINGNUf�9ER STALLATIONTYP fONSTRI;a�I�PE( F1 I , <br /> EVMNITORING _M_ HOlOWnEM BORING DEPTH -O OBOLTED nWFICBOX , OVEPIPE <br /> E3 EXTRACTION Nevorhmo 13HAMNERO EN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTHEVEL WELL CASING DIA <br /> ❑ SOLVAPORPROBIs ❑ MUD ROTARY CASINGTHIOXNESS 4 t-AYPEOFWING:❑STEEL EMC❑OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes c Bodng DI& ( G�OIs:_casing Depth: <br /> M INJECTION(ne Soares,omno) ❑ HAND AUGER GROUT SEAL DEPTH Al 1j TREME TYPE TO BE USED: GEP ❑HOSE❑PIPE. <br /> L3OTHER ❑ 0111ER: GROUTSEALPIMPED? Iess ElN,o,IN a;imemFreef$DephIsSoFt <br /> WEW SD)l.aORING ws GROUTSPECIFICAIIOtdS c-g,YY 1C <br /> DESI'i2U911QN WORK TO OF,PERFORMED: DESTRUCTION METHOD:fCHEC,KAL THhTAPPLY} <br /> 9WELLS TO BE DESTROYED ❑OVER-BORE DUtMETERof indws to depth of feet <br /> WELL IDs O PRESSURE GROUT To depth of feat bebw su dace <br /> GROUT SPECIFICATIONS ❑EXPLOSM From to feet below surface <br /> TREMIET'YPET09t3USED [IAUGms Q HOSE 0PIPE El MUSHROOM CAP 03feetbetowuWaceor-feet below wrfaceifWest <br /> OMMENTS: <br /> •i ' r - �a1 �..�� �,� �. .h:=:aD.�:ltlFitiQ , ..,;�5`• ^+'..�^:�1�w <br /> K <br /> Signed TtUe/Company <br /> Print Name Ilk Date Lt <br /> DEPARTMENT USE ONLY l <br /> Application Accepted By �,� - +4 ?,t e�t�'-a a�f7 Date Issued: 9/.g 3/1 A31 _ •f <br /> Grout Inspection By/Dates: <br /> AestnirUon Inspection By/Datea: <br /> fjgfljtv1Sjjp Infnirmatfon <br /> FA Name PA Address FA# <br /> FA PE WP Reviewed By CIV <br /> O <br /> C1 G57 ❑057 AWorizedon for Other to Sign Permit ❑Wa lefsOomp O WorkePsComp waiver D E nsoechmentPermll ❑Access Agmetrsnt 0 LW Rage AI. <br /> COMMENTSICONDITIONS: ��+y�-� f-,�n.� v �� p,L �y�r �� +�r-tic p�t.� rvr <br /> 8RTYPE 'PE SC FEE INFO RMT REMITTED CHECKf RECV•D BY DATE SI RVICE REQUEST* INVOICES <br /> Permit $130 X. <br /> END 29-01 623-2015 Site Mitigation Well PermitAppilration <br />