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<br />License#
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<br />Phone -w -15-z - tie
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<br />City/State/Zip W: I VVI CA 967744 I
<br />RECEIVED
<br />nvironme.._al Health Department
<br />SP 1 5 201/
<br />ENVIRONMENTAL HEALTH
<br />I SE SITE MITIGATION NENCIMN G PERMIT APPLICATION
<br />For Wells and Borings Used for Contaminant Investigations and Remediation
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />48 Hours Advance Notice Required For All Inspections
<br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.
<br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards.
<br />Phone
<br />ProPertY Owner Cet ArtM 14/410i1& I
<br />Address 3c10 1?-03e ; 11e- fe-inc.-A
<br />C-57 Contractor ci,se.A '..);-'1* 1.-n3
<br />Address Cfm fie vi jee br;
<br />Consultant/Sub-Contractor S' r so u rCi'S CLIr r
<br />Address / 81; tin
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />Job Address
<br />Cross Street
<br />
<br />.ce
<br />s. 0 S-11-
<br />
<br />City/State/Zip S k -t-c 0,4
<br />APN 7 7 - O 011-
<br />Liar nttt e 441. I T.1-012g Phone
<br />City/State/Zip 14'(46 b 14 c o
<br />License#
<br />City/State/Zip te (. p 1.610
<br />ZO9 -Lig 3 -
<br />916- &sit -
<br />Phone 43251LO -6970
<br />TYPE OF WELL/BORING
<br />12 MONITORING
<br />EXTRACTION (Vapor/Water)
<br />..tit SOIL VAPOR PROBE
<br />SOIL BORING
<br />INJECTION (Air Spam Ozone
<br />OTHER
<br />WELL/ SOIL BORING IDs
<br />NUMBER INSTALLATION TYPE
<br /> 1:1 HOLLOW STEM
<br /> 0 HAMMER/DRIVEN
<br /> 0 MUD ROTARY
<br />PUSH POINT (GP/ CPT)
<br /> 0 HAND AUGER
<br />0 OTHER
<br />CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH j 0
<br />DIA. OF BOREHOLE •
<br />CASING THICKNESS I
<br />CONDUCTOR CASING 0 Yes IA No
<br />GROUT SEAL DEPTH c+
<br />GROUT SEAL PUMPED? 0 Yes igi No
<br />GROUT SPECIFICATIONS 4- a,
<br />v x-
<br />P -tf-ri -ooj
<br />FivIS - S v
<br />fig BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />TYPE OF CASING: 0 STEEL 0 PVC I. OTHER "re.0 tO
<br />Boring Dia: 3 V2, " Casing Dia. Vil Casing Depth.
<br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />(Note. Maximum Freefall Depth is 30 Ft)
<br />veonvio.4-
<br />cti-e A 1:22-vt-knvi
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY)
<br />OVER-BORE DIAMETER of inches to depth of _feet
<br />PRESSURE GROUT To depth of feet below surface
<br />EXPLOSIVES From to feet below surface
<br />MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />WELL IDs
<br />GROUT SPECIFICATIONS
<br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE
<br />COMMENTS: hi),Se --re impv ?re- S •
<br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with
<br />a in County Ordinance Codes and Standards, and all other applicable California laws.
<br /> Title/Company Em, ree s
<br />Date
<br />Signed
<br />Print Name I la) ft
<br />DEPARTMENT USE ONLY
<br />Grout Inspection By/Dates: I S Vei .1070 g Vit L-A 0/1311 1
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />Application Accepted By:
<br />
<br />Date Issued:
<br />
<br />1 . 1
<br />
<br />FA Name C.:,--k ' ' "."--Ny FA Address FA#( i , ,r k PR# f
<br />FA PE . ) ' % C' ( WP Reviewed By 7 Work Plan Date •- t 1 •
<br />0 C-57 0 C-57 Authorization for Other to Sign PermitGrci-Vorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement Ehead Agency Approval 0 MFR
<br />
<br />COMMENTS/CONDITIONS: ti,4,4.1,,,,,,, pi „,„„,ke, ,-,,k kc ,uutek ...,6 )„,-- •-rkt, LoASAY0,4041, 0 " C , 4:2 -4-1,--e- ci. VrA-ieo r e i'v be-s St....-ki
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<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE#
<br />Permit 1, ,) 3115 $152x 3 4--S-1 :24; 5,— L
<br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com
<br />EHD 29-01 08-01-17 Mitigation Well Permit Application j„-7.7 LiSla )_,(40Z-1 91 4 (6 ro c.) videl
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