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0 a '?eCD SAN JOAQUIN COUNTY &VZ N ��^ '-XENVIRONMENTAL HEALTH DEPARTMENT JUN 3 0 2� •` '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 FNp�Oh#'� T �6 �;•..:-;;:.N:P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:vVWW.sicehd.com 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 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic tion is made w compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. -WA•� "FEq Job Address y ZO W• YO s£/ut iFA%02. City/State/Zip /N, /'� TO CA- Phone 2z9-9 0-/0 O to Cross Street Resp LA P4 s ycstMifit Ayr_ APN Property Owner* Cf'TV o F MANTFcA Phone 240,1-151L Address -o p i — Ctnuc S-v• . City/State/Zip M f},�Tf c•4 C� 151;7 U C-57 Contractor A. �, F_ . License# 6$O 22 � Phone Za C,7 7 7"/W 6 Address 91 -7 5-AAv./ A.&. City/State/zip SSro Consultant/Sub-Contractor /' , G•F - License# i�$Q ZZ Phonaj 7f, 1677 -10016 Address �S7 S A v`/ U. City/State/Zip SST �,,K TO w,/ CA `5 S.?I)5 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 1Z. El BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA N ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER /VlOF SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING Yes No Boring Dia: 211Casing Dia: Casing Depth: ❑ INJECTION(Air Saarae,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH I1.5 1 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE APIPE ❑ OTHER ❑ OTHE GROUT SEAL PUMPED? 'RYes No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs -11 1?( - 44GROUT SPECIFICATIONS' t6 r r�AfVJ0 'ry DQ 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: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �J San Joaquin County Ordinance Codes and Standards,and all o er applicable California laws. Signed___j, Title/Company IV Print Name Cv I) Date ©6/3o f ZO I!I, DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: -bt ��tjl7 17 fJ�dl Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# 1 O0�;j' ��.k TP R#ToS•f FA PE WP Reviewed By C< v3ait Work Plan Date 4% /} -I Zo Ve- E3'C-57 ❑C-57 Authorization for Other to Sign Permit E6orkers Comp ❑Worker's Comp Waiver ncroachment Permit ❑Access Agreement ar6ad Agency Approval MFR COMMENTS/CONDITIONS: 'p,-r-Ha,&4 Gam�prc-.,f sh wed be- nec& &-i ov o4o4f l"6ax-5'T SR TYPE PEZ SC FEE INFO AMT REMITTED CHECK# R/EC�rV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 2�?d J 5703 �jUYJ ✓ 21 /�p (r"N,y�� Permit �� J� $130 x '3977 Z/trU r�jvi/� r.jig/7f�_7 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application