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Job Address
<br />Cross Street A wrovrA APN I (h2-4- - 1 (-1 °r`c,i)
<br />Property Owner* 1 Vak14-, 0-vtd ¶& A 1A+D Dt tt Phone V
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<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 />d430 er-tst. GLIA.br icr tAieLi City/State/Zip (-47-4-ilDV\ C,P\ ,
<br />Phone qii)i--ut)-i
<br />Address ;
<br />C-57 Contractor
<br />Address Oi I -r,,,,m
<br />Consultant/Sub-Contractor lit,r+NNe,
<br />Au • IA EP
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<br />INSTALLATION TYPE CONSTRUCTION SPECIFICATION
<br />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 />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth:
<br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft)
<br />GROUT SPECIFICATIONS
<br />HOLLOW STEM
<br />HAMMER/DRIVEN
<br />MUD ROTARY
<br />PUSH POINT (GP/ CPT)
<br />HAND AUGER
<br />OTHER:
<br />BORING DEPTH
<br />DIA. OF BOREHOLE
<br />CASING THICKNESS
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<br />SAN JOAQUIN Environmental Health Department
<br />C OUNTY ?c,k) m.e.A,Ak covJ tAArA 4-51.7 Z3
<br />City/State/Zip SCAAAA....e__ ( () .
<br />License# Uc1..5--Cr Phone U(22. I7-6
<br />City/State/Zip 40-Ds, at, qs-063 1570
<br />kPhone 410 -I DOI License#
<br />Address 1017- 071 Ave...,
<br />
<br />City/State/Zip C)/Ct f_10.4j 1 CA 7qte0 (4.)
<br />
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />
<br />TYPE OF WEL1JBORING NUMBER
<br />MONITORING 0
<br />EXTRACTION (Vapor/Water) 0
<br />SOIL VAPOR PROBE
<br />OIL BORING i 0
<br />INJECTION (Air Some. Ozone) 0
<br />Ei OTHER 0
<br />WELL/ SOIL BORING IDs
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />WELL IDs - Gt (O( 1-5 i>)
<br />GROUT SPECIFICATIONS
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY)
<br />OVER-BORE DIAMETER of inches to depth of feet
<br />PRESSURE GROUT To depth of feet below surface
<br />EXPLOSIVES From to feet below surface
<br />MUSHROOM CAP 0 3 fegt below surface or ill below surface if >3 feet
<br />1r, ()c) (ANA.
<br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE
<br />COMMENTS: Ad uojy,,,,-c, i&e., tx) ti 0
<br />S I. IPA.
<br />I he by 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 -po.Ari-v.e-r
<br />Print Print Name o- A-k-ko.-At^ Date 2- /1
<br />DEPARTMENT USE ONLY
<br />Application Accepted By:
<br />Grout Inspection By/Dates:
<br />
<br />Date Issued:
<br />
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<br />
<br />Stt_ 1tf.
<br />
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />
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<br />FA Name fv" ' P'^e,
<br />PI sAku bi,S trw*-4,-^"Mre--/
<br /> FA AddreSS ,,., ..-... FM C) 0 l4'-W.)PM 0S9 7(5/11
<br />WP Reviewed By )- - S Work Plan Date 2_f) 1 I g
<br />0 C-57 0.6-57 Authorization for Other to Sign Permit IBINorkers Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Aceroyal CNA
<br />COMMENTS/CONDITIONS: 1.0 c 1 iy., 4,46)4.-/ -h,_;" -; 4-k c>0_, A 11,-,k,it lot, - Iv t: to,- %,:_--, -1:-..„). -- -0-4- La Ai. A-N. c -r---b-c i-owv-s-\,
<br />V-e i've c ...---i-"'. %.44$4--,.„..-- .e.."mk s) Nwo4r-e-v," (.1., Vat- e1/4M- t W-e--44 ) CA r.dr", ,....-,-r-M 1 0,-"ii ciAsf aelldo
<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE'S
<br />Permit ;iLtky,;" ; i - $152x i i i L 1--A; ) -h11
<br />1868 E. 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 ltatigation Well Permit Application
<br />Signed
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