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I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />an J uin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company 511-0Sr- Geo 16)1,, <br />fil-V IC <br />Signed <br />Print Name Date <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />DEPARTMENT USE ONLY <br />Date Issued: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br />D OVER-BORE DIAMETER of <br />D PRESSURE GROUT To depth of <br />D EXPLOSIVES From to <br />inches to depth of <br />feet below surface <br />feet below surface <br />feet <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.c5WIRONMENTAL HEALTH <br />PERMIT/SERVICES <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 />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 />City/State/Zip I ra,c_ CA" 95-3V4Phone (2_09) 3 5-.471 <br />RECEIVED <br />FEB 0 1 2016 <br />Job Address <br /> Se K0.55 on <br />Cross Street <br />Property Owner* <br />Address <br />C-57 Contractor 1:11. v• i r- v el •..1 erv r o.1 6 6, et rev I As§ gc,(01 i-e_si -T-edtchse# (_ <br />Address 3011 I , ,,,- f. I i e..... <br />Consultant/Sub-Contractor pt EL (c.,45 <br />4:9 <br />,4ftesii. <br />Address 2- 5-c9 ( ott-i`op Pi-A.bL) <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 />0 MONITORING I=1 HOLLOW STEM BORING DEPTH 5-- 7 r es-0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />12 EXTRACTION (Vapor/Water) .14 HAMMER/DRIVEN DIA. OF BOREHOLE j-,.„ 0 MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA <br />0 SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING El STEEL 0 PVC 0 OTHER <br />0 SOIL BORING 11. 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />El INJECTION (Ar Sparqe, Ozone( 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. 0 AUGERS 0 HOSE 0 PIPE <br />0 OTHER 0 OTHER: GROUT SEAL PUMPED? D Yes 0 No (Note. Maxi urn Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs 6- I , B .1 , 6-3 ,13-.4- R-POUT SPECIFICATIONS 1-7 pe. i i i i lie.- Ce " ena <br />ii-c1 - 6,) K-g / 0 19/ 0-1-01 g-it 8-12„ / <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED U AUGERS El HOSE U PIPE <br /> D MUSHROOM CAP D 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: tam k 644 , fe ye‘/ 0/16/ 7 4 , aie. / z 3-44‘te.--.1 rii/4.4'e .1-4-C- v)/apcu-ke/ <br />,71 <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan 2903 5213 59c/ i 4 36_, 6572g4 C.I/T - 2//li .5R oo71 /2 7 <br />Permit a 9 05- 3\3 $130x -7- *39c • 097296 c,tirk_ 24//, Y icao 7 2 / IzE , <br />EHD 29-01 6-23-2015 <br /> <br />Site Mitigation Well Permit Application <br />APN 1.)c) 1 80 " <br />5k 7 L've, oet,4-tedi) <br />1_5-00 i<,55 „„ City/State/Zip Trac, <br />r 95-3ot <br />- ?c-97O Phone <br />City/State/Zip Af4.675 Cfr 9 5-.490 3 <br />License# Phone(1) 746-0000 <br />1^1•Jr,44- Crek-iCA- 43-97 City/State/Zip <br />Phone g 35--,,7 4 74 <br />-625-2