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/ T•/,' Date Issued: DEPARTMENt LISh ONLY Application Accepted By. 44;',..1/ e/t6/57 Grout Inspection By/Dales: DATE RECVD BY CHECKS Site Mitigation Well Permit Application EHD 29-01 6-23-2015 Destruction Inspection By/Dates: Facility/Situ Information FA Name FA PE 0-57 CI 0-5TAnhothellonforOthertoSi9n Penn VVP Reviewed By CI WerteesCom DWarker's Como Watver 0 Encroachment Permit 0 Amese Agreement 0 Lead Agency Approval 0 MFR Work Plan Data COMMENTS/CONDITIONS: SERVICE REQUEST'S Z22 (Aire 3/31/ / 6 ‘)°C, 7 '1,5 0'; /xi 0))Z, (207? . 5 AMT REMITTED SC 5 I 16 $130 x FEE INFO PE 2e-r5 SR TYPE Work Plan Mama INVOICES FA Address I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION ME 11100: rci-IKS ALL THAT Apply) # WELLS TO BE DESTROYED 0 OVER-BORE DIAMETER of inches to depth of teat WELL I(To _ . 0 PRESSURE GROUT To depth of _feet below surface GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface I RFMIF ME TO BE USED n AUGERS 0 HOSE 0 PIPE D MUSI ROOM CAP 0 3 feet below surface or feet belay surface if >3 feel COMMENTS: -'. ':, r /1-ret,:4, ./..., „09,-, e- 'rt., e..-..c fs)i • r kJ-, - C('4.-: r yie ,,:t (:./v-. ..., 1-- I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other eppficable California (MC Title/Company aM)14):St /LAj R._(- Oat r. plrY\ Signed _pLNaMe E 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL.TFI DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: ,aww.sicehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NUN-kl.1 UNDAtili. 1.1:1.tM1 I 1.):;I'lkE:i I MUM DA I E ISSUED Applications hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is made in compliance with San JOATIilleaninly Development Tine. Chapter 9- 1115.3. and the San Joaquin County Well tilolulardo Job Address 14 .40 ,i-Se -Plef ir /4\)e cityistatom, Lock: , (-44 c152-ti0 phone Cress Street 10 kfAl 541" e v- Ow( y, Si- elm AP N C '150 ac I rooutty Owner Ci Cc L c3k; Address 2.2‘ \A. i-ne_ Sh-eo k—OCQ: CA et 52 A 0 C-67 Contractor Gi(l/A DC c:s Address CV:r 11c:- Rd City/State/Zip TYPE OF WELL/BORING NUMBER fi Miran -an:NG __ o /it EXTRAc I ION (vapntY/ate-?,, . I ____ 0 1:1 SCSI VPPnR PROBE — ' 0 El SOIL BORING 1:1 0 INJECTION vs Sna,20, Qa1111 0 [1 OTHER BT WELU SOIL BORING Ds E--- lisj 7, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH I 35- 6- la BOLTED TRAFFIC BOX 0 STOVE E HAMMERIDR1VEN D. OF BOREHOLE 12 " 0 ma IIPLE CASINGS 0 MULT1-LEVEL CASING DIA MUD ROTARY CASING THICKNESS 7,..' ' TYPE OF CASING: Z.STEEL 0 PVC CI OTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING n Yes RI No Bering Die: Casing Ola• Daring Depth: HAND AUGER GROUT SEAL DEPTH -r cis- TREMIE TYPETO BE USED: 14 AUGERS n NOSE 0 RPE OTHER:.50n1 C-- GROUT SEAL RUKAREDT litl /es 0 No (Note: Maderom rrualall lpiti N30 Fl) , GROUT SPECIFICATIONS . Kii::fi SI- C 0 Ilke a \-- i (.1. ) 4.2 I t_51ii (, if rd 5 1)1,412. Phone License/ i-1 Fic it, 5- Phone City/State/Zip Kid-ale? i CA CP-1550 Consultant/Sub-Contractor k/..)corer ikocks Crw4ca. von Licenser/ Cp 3S2-1 Phone Address 23 teo VA4c •Y1C, r s4,, Dr, sw.. -2- *-\ 3 City/State/Zip AVvY101(ACA1 CA clii SC31 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offaite Borings/Wails Require Access Agreements or Encroachment Pamills RECEIVED MAR 31 2016 ;NVIRONMENTAL HEALTH PERMIT/SERVICES 2_69-333 -4461 6 925 -3)1 -Swo ,c7n-611-2097