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RECEIVED <br />SAN JOAQUIN APR 6 2 2018Environmental Health Department <br />--COUNTY ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <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 />Job Address 214 S. 6 gowtt. e• r f I kG City/State/Zip 1 r. 1 , CA 9'6-2 7 4 Phone .-v /A <br />Cross Street H z?o APN 2 33 <br />Property Owner' 4 ci Proje c.+ <br />Phone <br />Address 8 ss' So. s- LA) • 7 / I- 4- 4- ° City/State/Zip Aie /3td.o L , C A 9 2444' <br />C-57 Contractor a_ rt. • f 4 ÷-- rer k) ' j <br />Address '?& 2 F+2 ),,,; gt,4A <br />Consultant/Sub-Contractor t4,4 1, 4 cc_ - <br />Address 3 °Co I 4 r- 41 8 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING _.2. )3( HOLLOW STEM BORING DEPTH 10 - 9 61 -er 0 BOLTED TRAFFIC BOX XI- STOVE PIPE <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 2 — 5' — 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS ,5-cii- 4-4.' TYPE OF CASING: 0 STEEL 15KPVC 0 OTHER <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS <br /> <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 3feet 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 />San Joequin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed Title/Company •P r c 4 I"A /IVA /(*ez. ki,4 ; A-Ci° <br />Pnnt Name th e 7-4-*/ 4 Date 3 / <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 />FA Name FA Address FM PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE Sc FEE INFO AMT REMITTED CHECK* RECV'D BY DATE WELL PERMIT* INVOICE* <br />Permit 5152x <br />1868 E. Hazelton Avenue l Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigabon Well Permit Application <br />?of- Z2? -774E) <br />License* C S - ç. 2 1 4/ Phone q4-1,1f-g(rF <br />City/State/Zip g 1 0 Ci CA <br />License* C H $0. .2q9 /PC* 6762- Phone q /4 • 2- 14144- <br />CitylStateiZip 1.3 4+ cc-e:. ( <br /> 0 MUD ROTARY <br />PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />ID OTHER: <br />WELL/ SOIL BORING IDs sG S-C 7 9 <br />"A Lt.-A .4-- 7- "4-LA..1 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL Ds <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Stara. °zonal <br />OTHER <br />CONDUCTOR CASING 0 Yes Xlo Boring Die: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH . TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE xt PIPE <br />GROUT SEAL PUMPED? ,g Yes 0 No (Note: Maximum Freetall Depth is 30 Ft) <br />GROUT SPECIFICATION pJe,, .1- Cco „ ... — - I Si, ... <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE