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DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: IZ//5 /1 ? <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />RECEIVED <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and RemedVrb <br />5 2017 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance F - .,ce Req. d For All insp ENVIRONNIENTAL IlEALTH <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work dem reARTMENT This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaq Only vvell Standards. <br />Job Address <br />Cross Street <br />18)16 Covty C -6Itid• <br />tfi-SSirr•-• ioa. I <br /> <br />City/State/Zip 51-it hot r C 9cu'i <br />APN 12.3 - I9(-01 <br />Phone <br /> <br />Property Owner* Hai y F ile..,. 5a...,ck?..-. Phone <br />Address /(, 5 5 is,). OA ix o t- f- City/State/Zip Stacir--t-in‘ t Cif trzc.)3 <br />C-57 Contractor '- c i4 2L1 c • License# 15 f'70 Phone <br /> City/State/Zip ite-f-o5 c../4 15-00 3 <br /> Phone SzVi2.— 7( 3r <br />fe,,,,-,•4,. AZ- '5". -ce I <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Arrvbcs Agreements or Encroachment Permits <br />Address et/1 7-4jk Ad, `Pr <br />Consultant/Sub-Contractor Consa /hiti <br />Address fr it R" 5.v.• tei-vat ter- AVG . <br />License# <br />City/State/Zip <br />TYPE OF WELUBORING <br />MUNI1 OR/HG <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />HI SOIL BORING <br />0 INJECTION vie Searle. oionri <br />OTHER <br />WELU SOIL BORING IDs t <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 HOLLOW STEM BORING DEPTH 4:- 23- 0 BOLTED TRAFFIC BOX 0 STOVE PIPE g HAMMER/DRIVEN DIA. OF BOREHOLE 3" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING OtA <br />0 MUD ROTARY CASING THICKNESS ,1,44 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />is .0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />_CI HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: CI AUGERS 0 HOSE 0 PIPE <br /> 0 OTHER: GROUT SEAL PUMPED? Dyes 6) No (Note: Maydrnern Neal Depth is 30 Ft) <br />11. rv 3-4 GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br /> <br />DESTRUCTION METHOD: (CHECK ALLTHAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS: <br /> <br />Signed <br />Print Name ate I I iz 7 /11 7 <br />I hereby certify th t I .am authorized to complete this application and that the work will be done in accordance with <br />San u County Ordinance Codes and Standards, and all other applicable California lar. <br />le., <br />m th <br />--(Ze ' Title/Company err1,1- 4 - .5-c.,'44.% 4i-St i,1 2 <br />D <br /> <br />FA Name <br />.4.1......... <br />Ce (J7 6 (tieik \FA Address 1 61.44,..41 (11/4, .s„,--74, FM OD 3 —7 7 pRof <br />FA PE <br />`C—C' <br />WP Reviewed By Work Plan Date it 2)7 ( 7 7 <br />Cg-t<5z; 0 C57 Authonzabon for Owe to Sign Permitii0<iter's Comp 0 Worker's Comp aver 0 Encroachment Permit 0 Access Agreement 0 Lead A Approvalin.‘R <br />COMMENTS/CONDMONS: 6 0,4_ , A._ ),,__ 4- c....Q...A.-2.-A (A.s--i , <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK* RECV'D BY DATE <br />, <br />WELL PERMIT# INVOICE* <br />Permit Z.(6) c>i ) $152x _. '--Y 11 .5-6 3 '11,‘")? v-- —17-//)4 7 1-/P0-0 3 7 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.s.icend.com <br />pEHo 29-01 08-01-17 Site IVitigetion Well Perm+ cation w 4 zra 3''7?st