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SANAAQUIN COUNTY FO0.x•73/ Greatness grows here _ Environmental Health Department Signed Print Name —rim 0T 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 County Well Standards. (1 L Job Address S. El Or...AA0o 'r City/State/Zip STO cAcTti..) CJ- Phone ViDif - C.) a Cross Street 5, L e 8 11.` APN j to - OS o - Property Owner* Ntc„5,.1),'^ -1-AJLN Irt^,\ 1"' 9 0 ,NAR. Address -3 "PA DRI'v City/State/Zip .Y4A./ Ls LA ci 3A4 Address ¶7 5 'Viva Ra4 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLJBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS CI MONITORING X HOLLOW STEM BORING DEPTH 5.' Pr 6BOLTED TRAFFIC BOX 0 STOVE PIPE Xl EXTRACTION (VaporNVater) 3 ar 0 HAMMER/DRIVEN DIA. OF BOREHOLE g - MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA NA- SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS 5.4„ ki 0 TYPE OF CASING: 0 STEEL AVC 0 OTHER SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes No Boring Dia: 1,4 fat Casing Dia: ,v,A. Casing Depth: t*,/ A- DESTRUCTION METHOD: (CHECK ALL THAT APPLY) OVER-BORE DIAMETER of inches to depth of feet PRESSURE GROUT To depth of feet below surface 0 EXPLOSIVES From to feet below surface 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet COMMENTS: TEA: j,j crlc p12 rsj cAoi z, 2. AT I hereby certify that I am 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. Title/Company .; T MAAA(cvs") A - G J. C.R)) Ar Date 12.^) 7- 2_, (2'4 Phone 90S'-Z3 ir -211 C-57 Contractor Al I wel ) 4 b404.0com(il A- License# 348- 36- 1 Phonc(_CI I ON 3 53 s5 Address 3 )(A ;-1- 2-c.-e rA IP ,../24-- City/State/Zip Aut.},,, C.Asi A , ci8 Consultant/Sub-Contractor A • G‘ a • License# t3 V a L2-7 Phone t‘i) 4 ‘P7-4 CIO SO City/State/Zip 5 ToCA. Tt)"../ ) cpt- cic 2...‘5-- X.INJECTION (Air Spam Ozone) a 0 HAND AUGER OTHER 0 OTHER: WELL/ SOIL BORING IDs V \ov -1 ‘./ *A.; - xt f v 3-11-S•*. I , -LAS - DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED GROUT SEAL DEPTH SIB' TREMIE TYPE TO BE USED: El AUGERS 0 HOSEXPIPE GROUT SEAL PUMPED? Yes FI ,Ipl No (Note: Maximum Freefall Depth is 30 GROUT SPECIFICATION T- E_ WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED El AUGERS 0 HOSE 0 PIPE Application Accepted By: Grout Inspection By/Dates: • DEPARTMENT USE ONLY Date Issued: /It Destruction Inspection By/Dates: Facility/Site Information FA Name i44; 1 IAA Pr, ,/1-1 FA Address LIS-Lf s, ii.! (Away 51--FA# 09 .4 7,.. gi,k PR# c)si:i VP Reviewed By 4---, x ork Plan Date FA PE .2-cl to 0 ID C-57 Egft<7 Authorization for Other to Sign Permit 13]-Worker's Comp I: Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement atfa-d Agency Approval COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit .211 0 ‘ 3 0 r•-- $152x 5 2svAS- il (ko 26-346- L)"((1 )11 it) 1°00 31 t Y 3 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com END 29-01 08-01-17 Site Mitigation Well PeOt Application .)1/C,; <1.3 61_4 iSL 1CZ-957 L Y 14'1