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Environmental Health Department
<br />SITE MITIGATION WELL &BORING PERMIT APPLICATION
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />24 i`iOUrB Advance �iotice Required For All lns�ections
<br />BALL 1209) 953-7697 For 1�9SPECTI®NS
<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 Address
<br />City/State/Zip ��-S=°,�-�-�,� �� �S'�20� Phone ���-- ti 2'� - � e'1Z
<br />Cross Street � ,„,, ,,e {, �� �- APN � 3� -�- �t� — � � �,
<br />Property Owner* �� t=; j `�,;1���#� �'�.��,� [._g�� Phone ��O �-� 23 -"� / 2'�
<br />Address 3+0� tn� �'j.�.�n 'j=`:., ,�� � :� City/State/Zip �j�,,,,�,,Q��,� Q c�f�, �Z����J
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<br />ConsultantlSub-Contractor .���, '(�,,,,�,�-'�,��;�-�,�,� License# � �"�. �-U l bt�b Phone '`� E� m � � � `" �'� t �
<br />Address �� bO �r3LV�ta.�n.� „��,'� City/State/Zip '�c�.:�.,�,-`'S ':���r—� '�� � �-I �"�i �-
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />TYPE OF WELLlBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH � Si , . � �� ❑BOLTED TRAFFIC BOX ❑STOVE PIPE
<br />❑ EXTRACTION (VapodWater) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE Z . �� �' ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA
<br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS P-5 �'+ TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER
<br />[� SOIL BORING�'�,, ❑ PUSH POINT (GPI 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 />WELLI SOIL BORING IDs S�3 � � � S� 3 GROUT SPECIFICATIONS #�.•F,--� �--� c� �..ti;'S .— en..�-�'� Ce_.:�v�%
<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 />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 if >3 feet
<br />rth.atl am:authorized to compiete::.this application.and
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<br />Title/Company
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<br />Application Accepted By: _
<br />Grout Inspection By/Dates:'
<br />Destruction Inspection By/Dates: �s�� r��14 � ZAP
<br />FacilitylSite Information
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<br />Date Issued:
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<br />❑ C-57 7
<br />Authorization for Other to Sign Permit
<br />❑Worker's Comp ❑ Wo`rkers Comp Waiver ❑Encroachment Permit ❑Access Agreement
<br />❑Lead Agency
<br />Approval MFR
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<br />FEE INFO
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<br />RECV'D BY
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<br />1868 E. Hazelton Avenue ( Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � vvvvw.sjcehd.com
<br />EHD 29-01 04-04-d7 Site Mitigation Well Permit Application
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