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�� `� ��� <br />�...� %W t� � 7» Sys � .9 Ld � 01% ih� .A 1 3 E: f 0.�� < <br />SITE MITIGATION WELL &BORING PERMIT APPLICATION <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,S� aquin County Well Standards.. ' <br />Job Address � �� City tate/Zip��(� c�l tl� � Phone �� <br />Cross Street <br />Property Owner* <br />Address ��j�,, <br />C-57 Con <br />Address <br />Consultant/Sub-Contractor <br />Address <br />�� <br />f <br />APN <br />Phone <br />City/State/Zip ���� � � �1 <br />License# �]2o�,i��1 Phone �l��i�yb� = �U(� <br />City/State/Zip �ryu�C,� GSb�j 2 <br />License# <br />City/State/Zip <br />Phone ���b)3� 2` �t"'�'�`1 <br />C�C�� <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells 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 (Vapor/Water) ❑ HAMMERIDRIVEN 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 (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 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 ❑PIPE <br />COMMENTS: <br />Signed <br />Print Name <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 />.❑�MU`SHROOM CAP ❑ 3 feet below surface or feet bel�ow�s`u�rface if�>3Lfeet 3'/ <br />v <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 />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Title/Company <br />Date N I � <br />r. <br />Date Issued: <br />FA Name <br />���� � <br />FA Address <br />� `7 I � .(J <br />,✓ V`- <br />,,���y,,� <br />FA# <br />� �- f - � lJ.� <br />PR# <br />�,6� <br />FA PE <br />^ l <br />-� <br />WP Reviewed By <br />v <br />� <br />Work Plan Date <br />�12�u <br />❑ C-57 � �C-57 Authorization <br />for Other to Sign Permit <br />❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment <br />Permit <br />❑� A�c�ce%ss Agreements L)ead Agency Approval FR <br />COMMENTS/CONDITIONS: <br />S �� �^ � <br />1i ro v ` �� Cj ,�/ <br />� <br />� �❑� <br />�'V'(�L'� �""�' <br />WP TYPE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D <br />BY <br />D,AATE <br />WELL PERqMIT#/ <br />INVOICE# <br />Permit <br />nnPE <br />�vl� � <br />$152 x i <br />� 5� <br />��Zln� <br />Vv <br />Gov � e�l�,, <br />� 868 E. H�zeiton �vet�ue � Stouton, Ca�ifOrni� J5205 � T 200 468-3420 � F 209 464-013a J �NW.sjcehd.com <br />EHD 29-01 08-01-17 < Site Mitigation Well Permit Application <br />�3s� <br />