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TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />/fa SOIL BORING <br />El INJECTION (Ay S.aame 0/Ong) <br />OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br />.1in" et HOLLOW STEM <br />ID HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />L <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: WWW.Sjcehd.com <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <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 />Job Address tJ ••> e k C, )-“, <br />Cross Street N) <br />Property Owner* <br />Address 1-61-0 4-16-0 City/State/Zip ti&i.J<,.1„7X 1?1C-- <br />C-57 Contractor eq,2,14y License* cA (YiL/S-i TZolc4 Phone <br />Address CM 0.1-zo.0.1S / 3 '64:10 ,,i. CL 1\2_ <br />Consultant/Sub-Contractor 6_4474 ssivt ,..I s pAt e r i <br />Address <br />iJ <br />Li&V-11 gis,d di-2-/ <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />City/State/Zip S)-,, fr,„ c14.72_ Phone <br />APN <br />Phone <br />CIty/Statealp O,y- /CliC <br />LIcense# r.,) A Phone 714 <br />C Ity/StatealP fr,,, r (4 Lic-k <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH S - c" b ' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />CIA OF BOREHOLE 2,1' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS d A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 Na Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED litAUGERS El HOSE IN:IYIPE <br />GROUT SEAL PUMPED? 0 Yes Eli No Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS ;I: 1501 - c 4 .t b LI 11 <br />S'"N %-1 -) <br />DESTRUCTION WORK TO BE PERFORMED: <br />It WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED D AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />OVER-BORE DIAMETER of inches to depth of feet <br />El 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 >3feet <br />COMMENTS: <br />I hereby itytht I am authorized to complete this application and that the work will be done In accordance with <br />San Joaq in County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed Title/Company ICA.2-r1.4 SyS12.41$ P4c i F ;'- <br />Date <br />DEPARTMENT USE ONLY <br />Print Nan1e Ctt v.:As:744E1z_ Cec.f t_.,:,- <br /> <br />Application Accepted By: <br /> <br />Date Issued: %if/ i_cji <br /> <br />Grout Inspection By/Dates /17i — <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name 7 ' Lk--11)-'\ f..2--‘.:.> FA Address Ce-A‘grievt.-1€ PI Cillt)CNCc v FA# On 7 Li v k,3 PRO OS-4 <br />FA PE .---- „...•.1 nel WP Reviewed By I N(' Work Plan Date g ,p p <br />D C-57 0 C-57 Authorization for Other to Sign Permit 0 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK* RECYD BY DATE SERVICE REQUEST* INVOICE* <br />Permit 2„, ii t..,.) 1 i . $139x _.. 4 411 1.33-3 1,.. (-k: / ( i <br />Jr 5z_s 3ci <br />fl <br /> 0332.4' <br /> <br />SP-00 176'4 —1 <br />EHD 29-01 10-26-2015 <br /> (3s) <br />Site Mitigation Well Permit Application