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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 />ci 5t, .,,,P 3t,A 7010,1 5 fru/ <br />Fq,)1 1+1A 517V4 <br />Property Owner* rti "t ia‘ii, Li -k diAalitYI tit AVni't; GO <br />Address ')‘()C.1 5c,' Hil `YIN\ ic1 il -SI, City/State/Zip <br />C-57 Contractor ryt99 4) n it.t A 1 es v) License# 05 16 Phone 525 -31 3--5__Pis-, <br />Address 9 5- :-.) tio we t?.1. City/State/Zip 1144 A il ea ..) (A T V51 3 <br />Consultant/Sub-Contractor , ta cl Pew V0.1 Vyk),Sti f/Va, License# 1-)( -1 ¶11 Phone 530-(14/- 2cL,v2., <br />Address330 Caligt{4AP..! ( SI, 1 .0- 550 , City/State/Zip (406100 Alt) 01 5447 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 HOLLOW STEM BORING DEPTH , 0 BOLTED TRAFFIC BOX ID STOVE PIPE <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE ,„ , 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />N 5( PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Die: Casing Dia: Casing Depth: <br /> 0 HAND AUGER GROUT SEAL DEPTH z TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />El OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs (!°I (0 IP / qrtib GROUT SPECIFICATIONS <br />cf)-(1 A 11/( 10 /FIFA, <br />Job Address <br />Cross Street APN <br />1-1-(45 -1t0 City/State/Zip 510&kiivl (i Phone <br />ii- ()% <br />Phone <br />TYPE OF WELUBORING <br />0 MONITORING <br />EXTRACTION (VaporANater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Soarae Ozone( <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED <br /> <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs E PRESSURE GROUT To depth of _ feet below surface <br />GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED 0 AUGERS El HOSE 0 PIPE <br />E MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />an Joaquin County Ordinance Codes and Standards, and all other ap licable California laws. ,. r <br />Title/Company p,j (7 <br />o <br />qviciy4- 51yelitis Frivptn ylikkt , Sy, 41 4 <br />J <br />Print Name <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Ncv_cv 7A- <br />FA Name 1-; ri,vv Q404:- i'N ievv`-1- FA Address . - - - ri„,..„1 S-j-- FA# 002_4314A PR# oct.1 z j3 L7c— <br />FA PE (:' (.- WP Reviewed By t .. -- )( Work Plan Date <br />I <br />I=1 C-57 El C-57 Authorization for Other to Sign Permit P Workers Comp ID Worker's Comp Waiver 0 Encroachment Permit Er/Access Agreement 0 Lead Agency Approval 111-5IFR <br />COMMENTS/CONDITIONS: (.._,.--,,; %,,k- s.o:.46& <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE* <br />Permit :). Jr/ ),- , $152x 7 4-1k 'A c6 6 -<,(l'6 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />Signed <br />44 6 4.16- Date "1-13-16