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0� • � c SAN JOAQUIN COUNTY 44 RECEIVED JAN 3 117 ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 E RONMC'TALM.°:i.'N .P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.c6 n SITE MITIGATION WELL & BORING PERMIT APPLICATION c(4.r.4, 4 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 application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 32.4 G• l/ fih 3fireet City/State/Zip T ak- c-1 . f.:'.il6,PhoneU�-7 _01q y6 Cross Street t5cLSt S i-ree-+ APN 1.'35 —/AQ (75-- r PropertyOwner' I-ragr . 0-1�10-iCe- Phone ` q(V) 2 - y�jj( Address .32q E• /( *h S tree'}- City/State/Zip 0.c� CA 9.53 76 C-57 Contractor /e A ` License# C10(P Q Phone Address 2 2d /V, 0.St S free City/State/Zip woodle d,CA 9577& q L Consultant/Sub-Contractor�a naPa �VIVs�/0J1 /� gnfo-' License# �3 Lt Lt 11-� Phone Address 17 1. X2 U 1-rcnkl; 5�722f 00 City/State/ZipQgk�Cn l-,C4 9YL /Z. CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ElMONITORING ❑ HOLLOW STEM BORING DEPTH lotElBOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ElHAMMER/DRIVEN DIA.OF BOREHOLE a. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER `SOIL BORING El PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes El No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaroe.Ozone l ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER OTHER: h GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs ; — Z , 13 GROUT SPECIFICATIONS 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 E-1MUSHROOM 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 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Fre%tCt G% b4osF 19c ZbAve �nw,�0!)Nl�nfa/ Print Name a � Date 1/13/17' DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# &Z X79 PR# FA PE WP Reviewed By j/ Work Plan Date /12 7117 ❑C-57 ❑C-57 Authorization for Other to Sign Permit D Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval Ej MFR COMMENTS/CONDITIONS: SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit 2905 313 $139x P�-1'17 7D J� C�/� �� S.eae 7( 76y WpPw 29o3 5-23 7PAD 1tlXj �3v`17 X400-76769 EHD 29-01 10-26-20159ti'J4yl Site Mitigation Well Permit Application