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,,005ANJOAQUIN COUNTY ( Environmental Health Department Vre-LTiv\Ark- coi.A4tkrv\k6.-t-Aov• 5 67_3 3 2....._ SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin Coup_qr Well Standards. Job Address I 3 0 '".-e4 City/State/Zip c3tba-OV). , cp Phone s 61C2Pk7 C 3 I D)11110 0061 Cross Street A Lky-box s-t ArN (0-1- Ls- 5-10) Property Owner AI I Miht \)Cl.VI lAa fr c,v-s A t&-b DIsmavol (.-z- too " Phone 2 I26 - G`b (e() Address savAe_, C-57 Contractor ev‘v\tro V\ VkA,Wk--(.„ Co tAttio Address -2.70h 1"v-)1V PAIKAS ipti)t)e?, Consultant/Sub-Contractor 00,111-kiL( Ec Address )01'4- Z2-t'° e 1 City/State/Zip SCOAN.Q.- License,* City/State/Zip oc, t GAO q tou Aate icenseit G 6.1 5 '7?-0 City/State/Zip 'FOS CO\ ((c61.3 Phone CVO 3 (510) Phone t ° -1 00 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING 0 HOLLOW STEM BORING DEPTH I 0 4--}- lel S 0 BOLTED TRAFFIC BOX 0 STOVE PIPE EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA, OF BOREHOLE '2_ • ' ) 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER A SOIL BORING 2- a PUSH POINT (GP/ CPT) 0 INJECTION (Air Seam Ozone) 0 HAND AUGER OTHER 0 OTHER: WELL/ SOIL BORING IDs 3.(.? CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED V WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 0 OVER-BORE DIAMETER of inches to depth of feet 0 PRESSURE GROUT To depth of feet below surface 0 EXPLOSIVES From to feet below surface 0 MUSHROOM CAP 03 feet below surface or feet below surface if >3 feet COMMENTS: Adu -1-wo 1/301, I (1 `_> 41" ID V-31" to (--5 -i:Or SO 1 savsA ) YN21 e---)14kAl I hereby certify that tam authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Title/Company h, e_,/ s J— Print Name ma...yvov\ Date Application Accepted By: Grout Inspection By/Dates: DEPART 7T USE ONLY L Date Issued: 2 / /I Destruction Inspection By/Dates: Facility/Site Information S-et L. —X FA Name Aii irk ky...,: 1/0-4...+S C----A I v-;...LAQ r-v-A-‘) `•,4-- t..11‘.-Anettk-r-, FA Address CI y) E.g....A eit.......k-4..7‘,...)0.4 FM 00 2. \..i, 4 IV) PRIt 091.0lA ) FA PE gct 'i't) WP Reviewed By 1-- 'ic Work Plan Date ) 0 C-57 0/C-57 Authorization for Other to Sign Permit 04/orker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0441FR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO , AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit ,...„- ki , ', -7 $152x .,:, / *S4r ' - - .r,.., r i ,9 L --)`• 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application 2,914,3 >)4 t-i;.>---L /•1J 1\,1/4 t, 111\1