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SAN J O A Q U I N Environmental Health Department COUNTY Greatness grows herd SITE MITIGATION WELL & BORING PERMIT APPLICATION go - For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Xmpeli�in tion is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicatc�npliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job AddressyT "�� / Ve,"APhone� G/frr1� Lu ur �1n� T - !y/u.y/State/Zip s�Ci/��Ur CrossStreet ul/6 , Si7 P2f APN 1& 7- ��Z 3/ Property Owner' Phone Address City/StaterZip K C-57 Contractor ' License# Cl)' Phone ✓�� v Address IfIV-61 City/State/Zip 6-114)/1 �FV S-373 ConsultanUSub-Contractor ✓ c / [ . License# 3 0 — p Phone 7/`7z— &-Z G Address �5'Z v 1t City/State/Zip vl r /L A `L) CONSTRUCTION WORK TO BE PERFORMED.*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE ONSTRUCTION SPECIFICATIONS MONITORING _❑ HOLLOW STEM B ING DEPTH 0BOLTED TRAFFIC BOX ❑STOVE PIPE U EXTRACTION(Vapor[Watrx) ElHAMMER/DRIVEN DIA. F BOREHOLE ]MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASIN THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT} CONDUC R CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarce.Ocone) ❑ HAND AUGER GROUT SE DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER:_ GROUT SEAL MPED? ❑Ye,,r 1 Nn rNnto M-imum Freefall Deolh is 30 F0 WELL/SOIL BORING IDS GROUT SPECIFI TIONS DESTRUCTION WORK TO BE PERFORMED: D UCTION METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED 0R-BORE DIAMETER of inches to depth of'` 5S~feet WELL IDs jW -1 - 1 - - RESSURE GROUT To depth of feet below surface r GROUT SPECIFICATI NS ec c 1t- (� ;�+"c� ❑EXPLO VES From to feet below surface I v c►Od TREMIE TYPE TO BE USED AUGERS HOSE 0 PIPE MUSHROQM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 1/1'1-1( 2 +0 L- b ti,,Jcvt CAel'e.V -e GJ Zt-f. 1 t 1�c •cr�vlut ods 121r'i 11 I hereby certify that I am authorized to co ption a late this applicand the work will be done in accordance with San Joaquin County Ordinan Codes and Standards,and a!1 her aePlicable California laws. Signed Title/ Print Name J-/ifs { DateCompan as- D DEPARTMENT USE ONLY Application Accepted By: Date Iss;4b�l Ar `7 V Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Namern-.,r-5 FA Address 1-}'� Pr K1,4in FA# (j V ��1 PR# b FA PE 'Zq OZ WP Reviewed By ��✓✓✓✓ ,� . I Work Plan ate I ❑C-57 N C-57 Authorization% b Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement Nead Agency Approval ❑MFR COMMENTS/ ONDITIONS: fq MW3 f o ytL (t"* s 5� M 4-M WP TYPE PE C FEE INFO AMT REMITTED CHECK# RECWD BY DATE WELL PERMIT# MIVOICE# Permit Ia $152. S T ZqZp Ott 41 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.c EHD 29-01 08-01-17 Atte Miter ^�—�^`^^"^� K D 6 Cj