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RECEIVED <br />OCT 1 $m JOAQUIN <br /> <br />Environmental Health Department <br />ENVIRONMENTALcIPMAIT Y <br />DEPARTMENT <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 SGIA/AAM ZA ot .et 1(1 V .i5\r4 bA)rt City/State/Zip 5600,1 CA ci59147 Phone VI (g54COU <br />J <br />Cross Street LA V i \ Ok t1;1*( APN _OPotiL )44-251 <br />Property Owner* MO S,5 Gila/JO11064 OtAPAtt5 A550CijigY\ Phone VC0,5- (-1600 <br />Address ?, 0 k ")0-K V (1/00 City/State/Zip 54 (awl+) CA 958q -tAk a5 I <br />C-57 Contractor rCV ' Atl 4,4 145)1 1 SS t License# 415 UP 5 Phone V.5-313 -516.-0 <br />Address q50 utkvk 044 City/State/Zip filfirkeZ. 04 9 1-15-53 <br />Consultant/Sub-Contractor rajliS EAU k ark tiviittaii TO , License# 14; -N-1 1 Phone 00-504491-4 Z <br />Address 3 3.3o Goivfnyk 44 Di . , 4t 550 City/State/Zip aote/K Acliej cA q.568z 3 6;)11.e4 e1 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits .54-raihi SI 4(i <br />NUMBER INSTALLATION TYPE <br /> 1:1 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br />SOIL BORING 1._1151( PUSH POINT (GP/ CPT) <br />_ 11 OTHER: GROUT SEAL PUMPED? It No (Note: M ximum Freefall Depth is 31;1_4 0 OTHER <br />WELL/ SOIL BORING —0T-1 4/13 _GROUT SPECIFICATIONS <br />TYPE OF OF WELLJBORING <br />El MONITORING <br />El EXTRACTION (Vapor/Water) <br />El SOIL VAPOR PROBE <br />tg <br />INJECTION (Air Soarge, Ozone) 0 HAND AUGER GROUT SEAL DEPTH 46T; y 0 IRENE TYPE TO BE USED: 0 AUGERS 0 HOSE 151,PIPE <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING Yes TT6o Boring Dia: Casing Die: Casing Depth: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH d 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />up4z 5 rio <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br />0 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 />0 MUSHROOM CAP 0 3feet below surface or feet below surface if >3 feet <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 />an Joaquin County Ordinance Codes and Standards, and all o her applicable California)aws. <br />Signed IPb Title/Company /14iy - 5i 1 'e1vtm1 fvtiolit-tt;ir, <br />(.04-) 1fl1 At - Date lOjO g6 g Print Name <br /> <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />1-01-1-0/41 <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name &AA v„.,6,, firLve- FA Address &It v-,,..r„: Dr.v, FA# 0 d 2,,,t, 3 ( PR# <br />FA PE PE DA (Li C WP Reviewed By L X Work Plan Date 'LIM if <br />El C-57 12K57 Authorization for Other to Sign Permit 1124orkers Comp El Worker's Comp Waiver 0 Encroachment Permit EKccess Agreement 1:11‘d Agency Approval Ef/MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC ' FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 1:1 C,c -3 -) $152x .)._ <br />"301-i 41151 L. )C 1/0 ii0 In '1/4446 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application