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TYPE OF WELL/BORING
<br />MONITORING
<br />IN EXTRACTION (Vapor/Water)
<br />El SOIL VAPOR PROBE
<br />SOIL BORING
<br />gl INJECTION (Air Spam. Ozone)
<br />NUMBER INSTALLATION TYPE
<br /> IN HOLLOW STEM
<br />3 El HAMMER/DRIVEN
<br /> 0 MUD ROTARY
<br /> 0 PUSH POINT (GP/ CPT)
<br /> E HAND AUGER
<br />OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft)
<br />WELU SOIL BORING IDs /1-5 7-- 3 ihrez...)t, 4-5- /0 GROUT SPECIFICATIONS ri letki/A_ iete,//e-IS
<br />I I.) 111,0i-2., VW —in
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />WELL IDs
<br />DEPARTMENT USE ONLY
<br />5 /5P
<br />Date Issued: 0/1 7 Application Accepted Accepted By:
<br />Grout Inspection By/Dates:
<br />Site Mitigation Well Permit Application
<br />e 7 7//-S— 2—V0
<br />EHD 29-01 10-26-2015
<br />Property Owner*
<br />Address /agio/%6 anN , 0,0 I, ‘..s "'Dew(
<br />C-57 Contractor 4/--F 41L 5ev,'t
<br />Address Sciik- 4
<br />Address 2-5 6, t3064.4,, Vi;/-3-1 z-00 City/State/Zip 6e,ss Valley
<br />CONSTRUCTION WORK WORK TO BE PERFORMED: *Note Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />GROUT SPECIFICATIONS
<br />TREMIE TYPE TO BE USED D AUGERS 0 HOSE D PIPE
<br />COMMENTS:
<br />Consultant/Sub-Contractor " a,krics LLC License#
<br />City/State/Zip Sk,..k.//70 / Cfr
<br />License#C- 57 94 16 4/ 2-2)-1
<br />City/State/Zip Zuid„,„ 6r27(e,
<br />,S115-
<br />phone() 93 `—t7'/17
<br />0, l(A 74/2.
<br /> Phone ft Z.71-4/2.00
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY)
<br /> 0 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 />El MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet
<br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with
<br />San , Jo in County Ordinance Codes and Standards, and all other applicable California laws. ‘.7.,_
<br /> Title/Company 5.44/ov- 5/Aff 6_,We7...ii
<br />Jar, (..e....4,(, Date A!, /17
<br />Signed
<br />Print Name
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />FA Name FA Address i°,,.... :yis L.).00 ,,apoii .„ FA# (1,, (2, ...,// It PR# c.)s-- 6 / ' 7 7
<br />FA PE 2,-37/ 0 /1 i WP Reviewed By
<br />
<br />, / *
<br />11//// La......% V
<br />. Ar
<br />Work Plan Date ir / 3 / / 7,„
<br />El C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Workis Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval I: MFR
<br />COMMENTS/CONDITIONS:
<br />SR TYPE PE SC FEE INF AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE#
<br />Permit 2„' 0 f 3 i 3 $139x , L 2 I '7/ ; t; V)/ / 7 rc.)D '7/ ,
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />1868 HazeIton Avenue, Stockton, CA 95205-6232 EA/tofu._
<br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.comppirfsirk
<br />SITE MITIGATION WELL & BORING PERMIT APPLICATION Rt4ck7
<br />For Wells and Borings Used for Contaminant Investigations and Remediation
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<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 />RECEIVE D
<br />1114 I 3 2tiii
<br />/D.5 47'.e had
<br />S;.47,-) Z15,1 /41/4,ve--
<br />e4 q5215 Phone
<br />APN -oo6
<br />Phone (20 cO 47/6
<br />CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH //a,. 13),enN6c11011 BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />DIA. OF BOREHOLE I=1 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />CASING THICKNESS 5h go TYPE OF CASING: 0 STEEL LEI PVC 0 OTHER
<br />City/State/Zip Job Address
<br />Cross Street
<br />CONDUCTOR CASING 1:1 Yes 181 No Boring _Casing Dia: Casing Depth://a.()
<br />PIPE TREMIE TYPE TO BE USED: 0 AUGERBM HOSE ISI- GROUT SEAL DEPTH - —
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