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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <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 />48 Hours Advance Notice Required For All Inspections <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 />5,4t\ Sa.." q ,, <br />rq't 1)4', 5treci- <br />Property Owner* 11)5e_ -.1-eielA <br />Address ':(9.9 F164 ,5 <br />C-57 Contractor Cyli, A I les he) <br />Address 9 5 f ?k <br />Consultant/Sub-Contractor , -Ent/1'42.1 111),y, ti,171A-t, <br />Address330 C,atAlf4AP," ( Ek4 At 55-0 <br />City/State/Zip 5 tak /ti, C 4 cii zoc, <br />License# q351105 Phone <br />City/State/Zip AKA -A kt f z-,) (A q' 'La) <br />License# pc, 1 9 -77 Phone 53)-1,76,- xi,g-z, <br />City/State/Zip (4044(14 Avi I) CA c754,g <br />z <br />51- City/State/Zip chKi'v, 01261) <br />APN <br />Phone <br /> <br />Phone .2o?- 3V34 3,13e <br /> <br />Job Address <br />Cross Street <br />g25-313-53r;b <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLJBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING <br />0 HOLLOW STEM <br />EXTRACTION (Vapor(Water) O HAMMER/DRIVEN <br />SOIL VAPOR PROBE O MUD ROTARY <br />-S. SOIL BORING 1:5( PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparse, Ozone( 0 HAND AUGER GROUT SEAL DEPTH <br />WELL/ SOIL BORING IDs 00 1-5 A/Aft /p/E- <br />OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />111 OVER-BORE DIAMETER of inches to depth of feet <br /> <br />WELL IDs D PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS D EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED El AUGERS 0 HOSE 0 PIPE <br /> <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />BORING DEPTH 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA, OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING D Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 12 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <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 />S Joaquin County Ordinance Codes and Standards, and all other ap licable California lawo:h <br />C-1 <br />or <br />Title/Company P i e Aqnup - J I 5 EPIC/1.241 . 14414d2 1 S 1 - t f , J <br />Date 13--o <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Sre-e- <br />Facility/Site Information <br />FA Name 1-c . '.**4-' '-'4-A'" ' i '•^'<- FA Address .zoc.--1 s . ff 4 5 i FA# PR# os1.4223 6.s-- <br />FA PE ) CI (e' L. WP Reviewed By /- —3(7 Work Plan Date <br />C A tY 1 q <br />0 0-57 a6/-5-7 Authorization for Other to Sign Permit I:a4-orkers Comp 0 Workers Comp Waiver 0 Encroachment Permit la"; ccess Agreement 0 Lead Agency Approval a) fAFR <br />COMMENTS/CONDITIONS: 6...,eD.4 , - ,--k- C240.- ---n . <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit -I ) $152x <br />I° 9 S1 I '1'i / l / ..s <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />:,29V-)3 t <br /> I 1 )( et?-) s,.4,0---6s