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AQui>v� SAN JOA <br /> ��°•� ,o� QUIN COUNTY <br /> KC <br /> ENVIRONMENTAL. HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com <br /> d � <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application ismadein compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address ouo-t' r 5i�r l LV I II LrktciE Itylstatelzip _ T �, CA 10 Pone 21)1�1- <br /> Cross Street APN Z I- <br /> Property Owner* l `= PGU ro�c A Phone zU'I-M-t3?i� <br /> Address /tl4l 6e X77 e 5 City'statelzip dAP7"�tGFI--, G 'S�-7 G� <br /> C-57Contractor ee,+ 1I.//A/ License# 7 ���`r6`f' Phone <br /> Address ' Olve, _ 6�/ 1)eC/ ljZ ? <br /> Consultant/Sub-Contractor ' am 4v�r ,4­ef n4 <br /> License# (rh05U Phone -I ZS-- 3?(-5-5,)b <br /> Address (,�f a( 6'<1-S/1 -':�r City/State/Zip r Cal q ys-5-6 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0- J '�^ J <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTHHca ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> L1EXTRACTION(Vapor/Water) ❑ HAMMERiDRIVEN DIA.OF BOREHOLE err ❑MULTIPLE CASINGS❑MULTI-LENEL WELL CASING DIA <br /> ❑ OIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS^✓C- TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> OIL BORING � &-'PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes �IPo Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION[Nr Soarae.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREvIIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Fre&&Depth is 30 Ft) <br /> WELL]SOIL BORING IDs 3 GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP 113 feet below surface or feet bel%v surface J>3 feet <br /> COMMENTS: (/J`c- 7re,ut,e- rfOrrrl�tJ (r) eAeee Fo-jce�e?hbo7 af-heewlye- 4C&,rd t'.� etiJwr C&M?)e�e 7.0-ff>dL , <br /> I hereby certify that I am authorized to complete this application and that the work wit[be done in accordance with V <br /> a I a uin County Ordinance Codes and Standards,and all ot''hppera plicabi California laws. //4� <br /> Signed `` Title/Company U�•J� �L��dGrly� C otsu 11 <br /> 0 <br /> Print Name _Date 7­01s- <br /> DEPARTMENT <br /> 01."DEPARTMENT USE ONLY 1 <br /> Application Accepted By: (/G Date Issued: 614-11' 201-5 <br /> Grout Inspection By/Dates-, Ei12-2 Z Z/ f i Z!:415- <br /> Destruction Inspection By/Dates: <br /> Facilit !Site Information <br /> FA Name FA Adtlress FA#! PR# <br /> FA PE WP Reviewed By IWork Plan Date <br /> EIC-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worke(s Comp Waiver ❑Ercroachment Perrnit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: ( <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan {� S��j G3),Ob sZ)e(-Y) Z0725 C'PTC- -9l-'I 580073120 <br /> Permit �U j �j$130x 3�'ID,e 3 l� CC>-LT;�"' S)? 0073 12 B <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />