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City/State/Zip S To cACT0A, c-iPt <br />AP N 197 -474 — Of <br />Phone t <br /> <br />Phone 7 044, ‘061 <br />City/State/Zip MAiraett_tA CA- IS 73 5 <br />License# 1/440 Vt phone@ oti) b 1 AO 10 <br />City/State/Zip ST 14 cir.T00,,/ Coh- <br />License# SANkt A.% oot Phone SAakt 4s Ablike+! <br />City/State/Zip a I <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />)ilt, SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Sparse, Ozonel <br />OTHER <br />WELL/ SOIL BORING IDs 5 <br />Na‘UMBER INSTALLATION: TYPE <br /> I=1 HOLLOW STEM <br /> El HAMMER/DRIVEN <br /> El PUSH POINT (GP/ CPT) <br />HAND AUGER <br />0 OTHER: <br />svv - t_ <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY— <br />,14L,cititess arcrNt: ftt?re <br /> RECEIVED <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIOWEB 0 6 2018 <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br />48 Hours Advance Notice Required For All Inspections PERMIT/SERVICES <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 />Job Address S j 5 W. ci4 .1 kv.r v441 .. <br />Cross Street <br />w <br />C.. 144rE tr %,,,A.1 u . 1.-i•At a ho% E4- • <br />Property Owner* Doppia:, An tbAer I <br />Address I 1 COQ COseWl VraiD4ra Aohtl <br />C-57 Contractor Ativ*LE 0 G.., <br />Address F37 SAAvs' oA-0 <br />Consultant/Sub-Contractor 5ies."1. A Abe,/ t <br />Address <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH ii.:7.' BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 9 " 0 ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes No Boring Dia: IVA' Casing Dia: tar)A Casing Depth <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? El YesJAN: (Note: Maximum Freefall Ili 30 Ft) <br />GROUT SPECIFICATIONS Ps 1.14ealb -ri p t. <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED <br /> <br />El OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs 1:] PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS ID EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ['AUGERS ID HOSE ID PIPE <br /> <br />El MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and allther applicable California laws. po <br />Title/Company AO 1-1..1* 411" NAG-t/- A-..E. <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />LI C-57 0 C-57 Authorization for Other to Sign Permit 0 Workes Comp 0 Worker's Comp Waiver El Encroachment Permit El Access Agreement El Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <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 Site Mitigation Well Permit Application <br />Signed /NM ea#1010,...-- <br />Print Name —rir" CNI t. )1" r Date 01, 113tOt