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RECEIVED <br />DEC 2 9 2, AN <br />UNTY <br />ENVIRONMENTAL HEALTH ,,s glows ik <br />PERMIT/SERV!CES <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 2 94:3o corr. I )4. Moo} Roe City/State/Zip 7i"Ce7,CA t53 7- Phone p/A <br />Cross Street ;) L Nivy 53P APN 253 - 3" <br />Phone <br />Phone q ii‘ - 131— 41"4 <br />Environmental Health Department <br />Property Owner* 'rr a al frI :1 Prej'ac 4. ow We. L. L. C <br />Address SP g g 54i1. 4A 4— 047 co:4c led City/State/Zip AMP) , CA 1'246.-0 <br />C-57 Contractor G 101 F 4 Strio:4J License# C51 - /6 4 22 <br />Address 3 36 2 F -:+29 er -At ( g <br />Consultant/Sub-Contractor PA /I4 ASSOC.-4,11 <br />Address 3 .5 t> <br />City/State/Zip R4**-01*.v 6r4.(14. c.1 /4 f5-7y Z, <br />License# c ft* 2 9 1 /P 4 JI 2. Phone q 14 " 2- /9..1744 <br />City/State/Zip wo 4- Sit Grs cA ?S-1i <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />NUMBER INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br />0 HAND AUGER <br />OTHER: <br />4 <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Suante. ()zonal <br />OTHER 0 <br />WELL/ SOIL BORING IDs 7 ItA Ix' <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH IP F1 0 BOLTED TRAFFIC BOX X STOVE PIPE <br />DIA. OF BOREHOLE g "3; A 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS SCi+ 4v. TYPE OF CASING: 0 STEEL vVC 0 OTHER <br />Boring Die: Casing Dia: Casing Depth: <br />(Note: Maximum Freefall Depth is 30 Ft) <br />-r <br />CONDUCTOR CASING *Yes 14No <br />GROUT SEAL DEPTH 6 ' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE M PIPE <br />GROUT SEAL PUMPED') lig Yes DI No <br />GROUT SPECIFICATIONS MC <br />DESTRUCTION WORK TO BE PERFORMED: <br />//WELLS TO BE DESTROYED <br />WELL Ds <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES <br /> <br />From to feet below surface <br />MUSHROOM CAP <br /> <br />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?r jt• AN 4 s^ it) Gt. <br />Print Name AA 4 + 4* Al AA? 7;04 Date ).;1 1. P <br />Signed <br />KvAl 41. A Bye .7',/ <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Workers Comp El Worker's 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 REMI1TED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application