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<br />t 9. SAN JOAOUIN
<br />COUNTY
<br />c)\°
<br />07'
<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 /><ZOO
<br />Job Address 13 0 .7-C:a 54- avA. A-R-Ar kA)Ck/ City/State/Zip (7) tocl--i.o Phone (510) 4410 —10(:)Ci
<br />Property owner*Ali iv( Vck.‘^` A- a It4 '104•4-S A v.-FO DiIei
<br />Address SCL 1M,e--- City/State/Zip co"4 e_.
<br />6q5-q710
<br />Cross street A u. kr0 rrA APN 10- — ?, 3 - 0 3 ( i-,c)Ir.t %Al s)
<br />C-57 Contractor EY‘1, t VNAW1 C.P141/1) I Ac,i0C-1 License#
<br />Address-50l1 TJM Pc.! iv Dirt e- City/State/Zip A ek.),
<br />Consultant/Sub-Contractor Par4440....,( License#
<br />Address 1 01 1- 72 A41 Ave', ct,., +6
<br />Environmental Health Department
<br />?c,ky evvt- (tryk-k-; o tf\ 0 3 6 (,85--
<br />City/State/Zip 00.004-4 CA qlco(.
<br />Phone (So) z121) Sca
<br />Ph(o8ne 31)(°6?---130115
<br />Plcge()) IRO -I OCR
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />TYPE OF WELL/BORING NUMBER
<br />MONITORING 0
<br />EXTRACTION (Vapor/Water) 0
<br />Al SOIL VAPOR PROBE
<br />ig,SOIL BORING
<br />INJECTION (Air Some. Ozone) 0
<br />OTHER
<br />WELL/ SOIL BORING IDs I —
<br />CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH (401
<br />DIA. OF BOREHOLE 2 . "
<br />CASING THICKNESS
<br />CONDUCTOR CASING 0 Yes 0 No
<br />GROUT SEAL DEPTH
<br />GROUT SEAL PUMPED? 0 Yes 0 No
<br />GROUT SPECIFICATIONS
<br />INSTALLATION TYPE
<br />HOLLOW STEM
<br />HAMMER/DRIVEN
<br />MUD ROTARY
<br />PUSH POINT (GP/ CPT)
<br />HAND AUGER
<br />OTHER: pl
<br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER
<br />Boring Dia: Casing Dia: Casing Depth
<br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />(Note: Maximum FreefaIl Depth is 30 Ft)
<br />DESTRUCTION WORK TO BE PERFORMED:
<br />II WELLS TO BE DESTROYED ',la
<br />WELL IDs
<br />GROUT SPECIFICATIONS
<br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE
<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 />0 EXPLOSIVES From to _feet below surface
<br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet
<br />COMMENTS: A ol v ay,c_..e_OAe -t-o \oCk cA.v%-cl NO0Y-11.1S 1-0
<br />r- • "Ate_ArloV touvLyA,c1 L
<br />,
<br />o ( IvcI1AX" SCA c\ac? 0,010 e-
<br />1 hereby certify that I am authorized to complete this application and that the work will belione In accordance with
<br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws.
<br />Title/Company 15 4.37_
<br />Print Name tJa.-HA.r.A.A.A May-0 0 N" Date
<br />Signed
<br />Date Issued: Application Accepted By:
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />DEPAJ3IMENT USE ONLY
<br />vv•Se(c40.4,-- re,p7i—
<br />J1 , 401
<br />FA Name/1 . i''Itt ` . :, "
<br />"WC° ‘-‘•„...s.fAc-v....,t1,4 ,7
<br /> FA Address ei 3, e 0),..„„As.e v \,..t-.1 FA# 00 4,41 /4.1 1/403 PR" C )C4
<br />FA PE -.)CI S-0 WP Reviewed By /_— X Work Plan Date
<br />-4 1 ) a
<br />0 C-57 El.-C-57 Authorization for Other to Sign Permit 13 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approvai ISI'FR
<br />CpMMENTS/CONDITIONS: 1; i:',,,,, 14-i--- • - • .....),,•• ' l.., !,:&,.-_,. .-„, — , , ,, --,,, t -, ,' -,,, _ ., Plc, , . .iloki 4).41),..tin erf , ,,.,, ..1_( .0......., sv.„.._.„..--;_t..i..... Th.,...) ...x.,,t,„,..., .t...,,,,z., ......-ei •eir c i,„....,..4„.% 6,.._ t7t, Lre u,;_,A i ci, .......icA,,....A.cv-tr_cal, ,5..- --at. €71 4.5 e...,„
<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECKS RECV'D BY DATE _. WELL PERMIT# INVOICE#
<br />Permit , , $152x , ' \ \ '';: e ' ..;-,. h ., ,'- 1 i.,'.,i, L'isg. g
<br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 I www.sjcehd.com
<br />EHD 29-01 08-01-17 -I • , S ite mitigation Wen Permit Application
<br />)( 3 4 `4 SI'r-) 2144,1-1t$ :
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