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DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of <br />0 PRESSURE GROUT To depth of <br />El EXPLOSIVES <br />o MUSHROOM CAP <br /> inches to depth of feet <br />feet below surface <br />From to feet below surface <br />0 3 feet below surface or feet below surface if >3 feet <br />SANJOAQUIN <br />COUNTY --- <br />Environmental Health Department <br />5- 14 FO n Greatness grows he: ' <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 />Job Address C-1(4E. (v.) City/State/Zip (e.,A 75-7,0 cf Phone AJ/A <br /> <br />Cross Street Fcc.,1.0;r1 A.c APN 3 oga- 2.c( <br />/4,1443-1( f>r• fr.) 5 <br />Address -3 535" td;-dk ,— Cie. City/State/Zip 5 4-DGICIDA CA 4 f C <br />Property Owner* Phone N/A <br />C-57 Contractor &rem r ;.5 +- CS+ " <br />Address 415-0 14 ow <br />Consultant/Sub-Contractor <br />License# 1./5"/ pc- Phone 41 75--- 3(3 - S-81°° <br />City/State/Zip MA.r4-in / CA eils-c-3 <br />License# c5-5 37-& Phone 1G c(6,51•01-- <br />C. <br />Gkito <br />Address 4106"0 GO(dactdo Ut,c. ,./4-e 13 City/State/Zip C_trvi-cron.. r1( <br />CONSTRUCTION <br />- <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />12I MONITORING 2.. ti] HOLLOW STEM BORING DEPTH <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE ff " <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS 5 ch. '10 <br />SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 5,1 No <br />INJECTION (Pr Sparoe Ozoriel 0 HAND AUGER GROUT SEAL DEPTH <br />OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No <br />WELL/ SOIL BORING IDs rn,...,- I 5 13 -{-• Mid I (0 A GROUT SPECIFICATIONS <br />El BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL PVC 0 OTHER <br /> <br />Boring Dia: Casing Dia: Casing Depth. <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br />ri WELLS TO BE DESTROYED <br />WELL IDs <br />AUGERS 0 HOSE 0 PIPE <br />COMMENTS: <br />I hereby 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 />Signed I Title/Company c s4.1f (.9 (-11) <br />Print Name <br /> S urn Date S-C) 8' <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />FA Name t i';" ''-'''' CArst"'Ll."' "-' 54." -A\-- <br />ci,%-1,4351-1 <br />FA Address c 2 ''':' "f' ' ---*k-YI ")") El'''11 FA#L.;,0-01 i R3 PR# i ' 1 ,;-u 7._ ,,... ; ' <br />FA PE ,-PI45)0 WP Reviewed By L— ,.X <br />ID <br /> <br />0-57 Eff -57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit Ll Access Agreement 0-Lead Agency Approval 0 MFR <br />Work Plan Date <br />(0itiet <br />COMMENTS/CONDITIONS: r1/4,v, S, Gy-rovvvir- biarot 1'...t.te/Y:k.d.k, T'vs.V... <br /> <br />pr-c. t..,',Q,./..4: L.) S.,---iovv,t -4.4 fre-Ak- <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit .2_0101 $152 x 1 •-i '3014) q iCii-i ',.,-)C 00'3.1 7 -qc . _ <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EI-10 29-01 08-01-17 Site Mitigation Well Permit Application <br />2$L 2-3 LAS (+; <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br />c3° 6f, —Y <br />s36bu