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Phone q16-760-7(o gi 4'1.4 irtek Address 3 3c* Si C.c.( et tow Ave./ 5.;+c 300 HS' DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 0 OVER-BORE DIAMETER of inches to depth of feet WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED COMMENTS: 0 PRESSURE GROUT To depth of feet below surface I=1 EXPLOSIVES From to feet below surface l=1 AUGERS El HOSE El PIPE El MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet Title/Company ‘c /(4 D 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. Print Name ettli• S44••• e•-tt Date 1117./ Application Accepted By: Grout Inspection By/Dates: DEPARTMENT USE ONLY -2<6 Date Issued: I s ) 1 re-por+ Destruction Inspection By/Dates: Facility/Site Information SAN4JOAQ„.N COUNTY Greatness grows hert. Environme..,a1 Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION .1,4 ,m1,.WJ For Wells and Borings Used for Contaminant Investigations and Rerhedi on "`" J 6L4$ 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. Phone Phone '2-09 - v35---qe)00 City/State/Zip getctcv4 t.w4-o qs-rzi License# tS-5 31 City/State/Zip Koseozh 4 i CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLJBORING 12 MONITORING EXTRACTION (Vapor/Water) SOIL VAPOR PROBE W SOIL BORING INJECTION (Air Some, Ozone). OTHER WELU SOIL BORING IDs NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 HOLLOW STEM BORING DEPTH El HAMMER/DRIVEN DIA. OF BOREHOLE 13 MUD ROTARY CASING THICKNESS 5 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING HAND AUGER GROUT SEAL DEPTH 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No GROUT SPECIFICATIONS 1'5 •11 13 -2, 3 -3/ 8 -Hi ZS o BOLTED TRAFFIC BOX 0 STOVE PIPE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER Yes 13 No Boring Dia: Casing Dia: Casing Depth: TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE (Note: Maximum Freefall Depth is 30 Ft) FA Name C-1) Cti'l L'i ct .VVA/(--(VA tlYW3 L FA Address ci%- vi (r-Jis- L1 .., t FA FA# ',Cit.( 3.-1 t. PR# FA PE 3S146' ° WP Reviewed By L - Y Work Plan Date i o i CI I ,,.... 0 C-57 2re--57 Authorization for Other to Sign Permit Ertorker s Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement E'ad Agency Approval LVMFR COMMENTS/CONDITIONS: la, G•r, -- J WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 29 tr3 -)t) $152 x 3 1) 4.51, -1 lio '15 1- -y,vl3h1 \1jr(9t->liko.> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 C 41s-Lx 14s-1 l it L Mitigati2131/Vg11 PermilApplication Signed S75 1.461- "i City/State/Zip i-retcii CA T ts 61/4 G4-j . C,Arrck" C7mAc. kect Es4-0-c- License# 913 II9 Property Owner* Address (-145 wesk- Sfri,A; S,,r4-e A C-57 Contractor c fkutemcd. Cult , APN RSE 1--Am`-ViGCS Consultant/Sub-Contractor &Wm Address ILI 3 9-•••ece_;r4i. bet w4- Phone eti(e.--th if -C7 77 ris-67Y City/State/Zip ?re, (.41 CA Job Address Cross Street