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SANAAQUIN <br />—COUNTY <br />Environmental Health Department <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Date Issued: /2 1 1 d <br />Greatness grows here. <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 />City/State/Zip Tv-z&cd , (A 5 311 Phone S .50 -991 Cil 00 <br />Cross Street N &u..119-‘i 5fX7 APN 't 2-6044 <br />Property Owner* .-to.A.,1Jov1(..S ArneAA <br />Address <br />C-57 Contractor Exp\ 0,0:6V0v\ <br />Address i 5 1n,-4)1 /4.ri 4 A•re: <br />Consultant/Sub-Contractor C.Ar\'0u) çc trICQ,(1. <br />Address -)-11 1-1 01) <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />Po R30 Lk-gg City/State/Zip IAA( q D040 <br />License# .eic 2--gg Phone <br />City/State/Zip StA..,\Al...VOSC-, CA- CI 31t2 <br />License# G-44-C i 02- Phone C )0 G3ez,-kSCID <br />City/State/Zip Oft.le_la., CA _t <br />TYPE OF WELUBORING <br />($1 MONITORING <br />0 EXTRACTION (VaporMaler) <br />0 SOIL VAPOR PROBE <br />El SOIL BORING <br />0 INJECTION (Sr Some. Ozone( <br />1=1 OTHER <br />WELL/ SOIL BORING IDs tL3 B <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 10' X BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 8', 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: LI STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes pi) No Boring Dia: Casing Die: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS El HOSE DZI PIPE <br />GROUT SEAL PUMPED? 0 Yes RI No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS °ir, b-e)/Vt-DY11-41, Ur/VAAL <br />NUMBER INSTALLATION TYPE <br /> HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> El PUSH POINT (GP/ CPT) <br />0 HAND AUGER <br />OTHER: <br />DESTRUCTION WORK TO BE PERFORMED: <br />4 WELLS TO BE DESTROYED <br />WELL IDs <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE D PIPE <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> El OVER-BORE DIAMETER of inches to depth of feet <br />D PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP D 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />P ° 1441th k- II OittV <br />Title/Company VCLe ettajetejack- CAr\XA iSrn ly)-(2,e <br />Print Name L.--k e7A Date <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name ':%e. I' j-> - en FA Address 1-1 i " (A"".1 qc."<" 4 f FA# 002_,L.4 (-1 - s a I() PR# - krii 3. kgo / <br />FA PE ,L)..ci cc/ WP Reviewed By r— ' Wort< Plan Date 7 ja <br />'-',--' <br />0 0-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Workers Comp Waiver 0 Encroachment Permit 1:1 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />VIM TYPE ' PE SC FEE ,INFO AMT REMITTED CHECK# IRECV'D BY '. DATE RMIT# <br />, , <br />. WELL.Ot' IV INVOICE <br />Permit $152x - , <br />I i , <br />- <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 <br />g I tcl <br />Job Address ..5)C1D71 0,4)41a.9-' <br />1-‘449- (02-3