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RECEIVED <br />JUN 1 5 201/ <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />APN <br />Job Address <br />Cross Street <br />cllb opl 2 515- ) <br />14( <br />City/State/Zip 5+Ktiin, ( (1 5204 Phone <br />Phone <br />Clty/State/Zip WOR+ (rctIC, C4 "fed" <br />License# <br />Ot, 1 City/State/Zip A.1,-, (ft <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note Cffsite Borings/Wells Require Access Agreements or Encroachment Permits <br />WELL/ SOIL BORING IDs SS - I <br />Signed <br />Print Name <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> <br />San JoaqIni iCounty Ordinance Codes and Standards, and all other applicable Californi laws. <br /> <br />AA/1/1/a PCiAtk Title/Company St4 f4 <br />S lin , I PgI tt Date <br />4 911 33011 /7.611-1 se_oo-ni -1 ..A.) 19 'LIG) r23 131 X 3 <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjcehd.com PERMIT/SERV10ES <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 />Property Owner* Cot 44/ Fut( rieli <br />Address 5 ,5 -7 <br />C-57 Contractor Cr ill ci Or.11:1 .4" <br />Address ISO P-4 . <br />Consultant/Sub-Contractor et ,ri i I n k <br />Address 6);s1 k AVI <br />Phone <br />city/state/zip Kiri AA CL( ctt cl‘t s 3. 1 <br />License# 31%O)4 S.- Phone <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH / ' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />OLA. OF BOREHOLE I. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DtA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes re No Boring Die: -- Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED . 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 2I Yes 0 No (Note: Maximum Freefall Depthi30 Ft) <br />GROUT SPECIFICATIONS 1.3e.t-ten trroit- -F. I <br />, <br /> - <br />'- iDocre ft - <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 />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />DOVER-BORE DIAMETER of inches to depth of feet <br />1:1 PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP D 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />DEPARTMENT USE ONLY <br />Grout Inspection By/Dates: L,--)( SDI (9 <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Application Accepted By: Date Issued: t * <br />1 <br />FA Name <br />I . \/,,i,, FA Address 2:-Ci-N‘jU444t3r1 C't." CL-A FM 6 0-2->41 ( 0 PROI ocl.t l ei Ft <br />FA PE ,,-,. WP Reviewed By L-_/' Work Plan Date 4, ) is-b 7 <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDMONS: f utc. tr,,vet4s., 40 <br />SR TYPE TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit /mu< rs 0 $139x I f- I 35. 3SD1 I 1----)( (0 (volan S(2-'0211111 <br />r„.9 u <br />)9' :,-Lirece--4- ''C.0 <br />- /2/71 1223 <br />TYPE OF WELUBORING <br />MONITORING <br />EXTRACTION (Vapor/Wateu <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Some. Ozone; <br />OTHER <br />NUMBER INSTALLATION TYPE <br /> ID HOLLOW STEM <br /> I: <br />HAMMER/DRIVEN <br /> <br /> o MUD ROTARY <br />15V PUSHP OINT(GP/ CPT) <br /> o HAND AUGER <br />ID OTHER: