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T <br /> SA N. OAQ U I N Environmental Health Department <br /> COUNTY <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 AddressAMC City/State/Zip —Phone <br /> Cross Street APN Ao <br /> Property Owner" Obb Ejvlof, PW ascm, L01I Phone SIN&0.1 <br /> Address S City/State/Zip 016 <br /> C-57 Contractor Irv► t& L LC License# S Phone <br /> Addres am" CitylStatelZip &!I�GrbA !70 C 4303 <br /> Consultant/Sub-Contractor License# Phone <br /> Address CitylStatelZip <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsMlells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING(DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapog)Nater) ❑ HAMMERICRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING. ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP1 CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing pia: Casing Depth: <br /> ❑ INJECTION(Air sparge,ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑NOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL!SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO RE PERFORMED- DESTRUCTION METHOD: CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED (-+art 1—x4PVG� " IOVER-BORE DIAMETER of inches to depth of"feet <br /> WELL IDs — PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS 1 CA MA4 EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED WUGERS ❑HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: SY rz —CA I—'+%% "a 46 AV * 1-4)t � 4% &.+"(PVC. W I <br /> 11 Vve, o AA � ' VIA-04p <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 a s. <br /> Signed Title/Company Y CJi I,44 <br /> Print Name Date <br /> DEPARTMENT USE:ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit 1Site Information <br /> FA Name FA Address FA# PR# <br /> FA PF WP Reviewed By Work Plan Date <br /> ©C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit [:]Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMM ENTSICON DITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV`D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 0e-01-17 Site Mitigation Well Permit Application <br />