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SANdOAQUIN <br />COUNTY <br />G r' k) 7. (HOW!, <br />Environmental Heath Department <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 />rhis application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards <br />Cross Street /I :14 &di. Si> ' <br />Property Owner* / /-4 c Al; 1),-, r 0 W.Iler• <br />City/State/Zip fr"7, CA 9537 6 <br />APN <br />1.4 c <br />Job Address 294 6'1, .50v1k a.rt. Phone <br /> <br />JL'IA- <br />Phone <br /> <br />City/State/Zip Pea NT Be. 0A, , CA I <br />License# C54 - 94 '42.24/ Phone //4 - 92f - /17 <br />City/State/Zip A J-"--t-L- ' 4 r-,04/4 £1-4 15'1 Z <br />License# C H Pti 2,1 / p6 ftt 6/42- Phone <br />City/State/Zip 101.5" -I- SA c,c "4-4-P i OA <br />Address ES g Sk.- 1"--e- , ID° <br />C -57 Contractor Gr. tr: Ckot-4- C4 ,1,3 .47=6.4) f.cv.ij <br />Address 316 2. F742 jerdetd. 0 et <br />Consultant/Sub-Contractor Ws I hi CAC — Avi-1 I!' 4SY, t:4 4-ef <br />Address 3o 6, 7 . 15'.' 8,fr'.-(d.r-e <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING xi HOLLOW STEM BORING DEPTH /0 '4% BOLTED TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA 4 ID PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Bonng Dia: <br />SOIL VAPOR PROBE <br />SOIL BORING <br />7 0 MUD ROTARY CASING THICKNESS di TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER 1-2, Fl.,.' Ti/13, •y.— <br /> Casing Dia: Casing Depth: <br />INJECTION (Air Spares, Ozonel 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER 0 OTHER: _ _ GROUT SEAL PUMPED? 0 Yes IF.4 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs SG I A / 1.8 - GROUT SPECIFICATIONS 0, ic...1- cf......-.> sv ...., 2 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />//4 <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS: <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 />o EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <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 County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company ?r c* Lg.; - e. /4- Aff„;,z, <br />Date <br />Signed <br />Print Name <br /> <br />h / k <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name <br /> <br />DEPARTMENT USE ONLY <br /> <br />Date Issued: <br /> <br />FA Address FA# PR# <br />Work Plan Date WP Reviewed By FA PE <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Workers Comp 0 worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />PE SC WP TYPE FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />$152 x Permit <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