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reatness grows hem <br />SITE MITIGATION WELL &BORING PERMIT APPLICATION <br />11 <br />For Wells and Borings Used for Contaminant Investigations and Remediation <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 Count�j ]Well Standards. <br />Cross Street <br />Property Owner* <br />Address �� <br />C-57 Contractor <br />Address 1 \�'�� <br />Consultai <br />Address <br />APN <br />Phone <br />License# <br />City/State/ <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />1 <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ' ' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑EXTRACTION (VaporlWater) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE �� ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS G, TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs , � W � i GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑ P_IPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />_ ❑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 />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface <br />if >3 feet <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 />Facility/Site Information <br />FA Name <br />,,y�a <br />� <br />FA Address <br />� <br />,�, <br />❑ C-57 ❑ C-57 <br />Authorization <br />for Other to Sign Permit <br />❑Worker's Comp ❑Worker's Comp Waiver <br />❑Encroachment Permit ❑Access Agreement ❑Lead Agency <br />Approval FR <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />1868 E. Hazelfic�n Arenue j Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � vvww.sjcehd.com <br />EHD 29-01 08-01-17 S�O��/ � Site Mitigation Well Permit Application <br />