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ti <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION MAR 2 6 2018 <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />E NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT NM' <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 2 94 s &S'ov+L Co r r I Ye Op 1.4) A City/State/Zip I r 4 c CA C 3 76 Phone <br />Cross Street H j 4/..)6./ 5 'D APR 2 3- 3 - 3 6 0 - <br />Property Owner ia C j : Pr jcc 0 c Phone 20f- Z2/ -77CD <br />City/State/Zip fkle L.' + cc , CA 9 Z <br />Liconse# C - 9 ci 2 1 Phone q14- - <br />City/State/Zip ge,. L0 Cr.', g e f <br />ucense# C H 19 9 //'C 6f 6 /6 2- Phone q - 2 - I 4'144 <br />City/State/Zip 1-)4'k Cc CA , 5--6g <br />k1/4 <br />Address 8Ss' 1,9 • 1 r/00 <br />C-57 Contractor a,(4- sk • .1 Ca •••• r Ct.^ <br />Address 3 3 G 2 F:-1-2 /2 R oo <br />Consultant/Sub-Contractor tiit• n <br />Address 3 so .1,- • etc- 4 8'( <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH /0- 9 0 7- O BOLTEDTRAFFICBOX VSTOVE PIPE <br />DIA. OF BOREHOLE .2 " 0 MULTIPLE CASINGS 0 MULT1-LEVEL WELL CASING DIA <br />g MONITORING ,77-71)3( HOLLOW STEM <br />EXTRACTION (VaporfWater) 0 HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING ^,- V**fr SI PUSH POINT (GP/ CPT) <br />INJECTION *Sanaa. Ozone! 0 HAND AUGER <br />ILO R: THER 0 OTHE LI <br />SOIL BORING IDs S G ^ i A - SG 7 9 <br />-1-- r•-• 14' I '4"' .7- "4. <br />CASING THICKNESS fch- 449 TYPE OF CASING: 0 STEEL IKPVC 0 OTHER <br />CONDUCTOR CASING 0 Yes No Boring De: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USECr. 0 AUGERS 0 HOSE XrPIPE <br />GROUT SEAL PUMPED'yll Yes 0 No (Note: Maximum Freefal Depth is 30 Ft) <br />GROUT SPECIFICATION t-I ii.. 4- C4,4".... - .... -f S1 o r •7 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK AU- THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />o EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 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 Joaquin Co Ordinance Codes and Standards, and all other applicable California laws. <br />Signed Title/Company 'Pr •ka " j.e /OA n - ka4 ASIpc <br />Print Name / e/-7:it Date 3 / / <br />*E ARTMENT USE ONLY <br />4 frtif , Lg ce\. \is) - <br />Destruction Inspection By/Dates: <br />FacIlity/Site Information <br />FA Name 1v'-ci l'i • SA . SA t. w%41"Acvl FA Address ;2-,tt (0%5;4 "S - ("Jr "4 1-1,0"'") FM 0-L ,LiN-I 1/44 PRrt C '1 '1_-_; 1 -) <br />FA PE acts-c, WE Reviewed By 1.-- )( Work Plan Date z i <br />0 C-57 cae57 Authorization for Other to Sign Permitaiorkers Comp 0 Workers Cornp Waiver 0 Encroachment Permit 0 Access Agreement 13.Lead Agency Anneal tg4,IFR <br />COMMENTS/CONDITIONS: 1 -- a , ty,---cl do->r,Se_p-i <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMITS INVOICES <br />Permit ,;,:kc k i'l, $152x *-:.: q ' I (4; 1- X kAlci, \ ji ,i7.,:::: G.:=1 <br />1868 E Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHO 29-01 08-01-17 Site Mitigation Mu Penrit Application <br />0, -/ SZ) 3 x , <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> (Date Issued: