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SA Q Environmental Health Department <br /> COUNT Y <br /> ` ct a `1 Greatness grows here . <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 /> 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 - 111 3 , and the San J a ui County Well Standards . <br /> Job Address ^ � City/State/Zip �UIC C C ' L /T Phone �'�� <br /> Cross Street N APN <br /> a /, Gt '7 •� A i' <br /> Property Owner* L� � 1� � ( , � � �,,, �� �, Phone`Z� c,�- IF � <br /> Address P _O 3 ri - City/State/Zip JM <br /> C-57 Contractor t ( IAn OWA yviC vnse# Z , 09 C9 L p, / Phone 2. 09, 1 77 � �� <br /> Address aJ ; V\A� y� v • t` �-� (qty/State/Zip f� Ar 56 I J�(!1 2 - <br /> Consultant/Sub-Contractor 17Vw ) N, t License# 9 �� Phone ?. O 16 0 (� <br /> Address 7 'ter - _ City/State/Zip <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 /> MONITORING _ HOLLOW STEM BORING DEPTH ElBOLTED TRAFFIC BOX STOVE PIPE <br /> ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE •'7 y ❑ MULTIPLE CASINGS ❑ MULTI -LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br /> El SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes No Boring Dia: 7 Casing Dia : " Casing Depth : `Z <br /> ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS HOSE IPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Yes ❑ No (NoT : Maximum Freefall Depth is 30 Ft) <br /> WELL/ SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) <br /> # WELLS TO BE DESTROYED [:1 OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED L❑ AUGERS [] HOSE E] PIPE El MUSHROOM CAIt PP 01. 3 feet below surface or feet below surface if > 3 feet f <br /> COMMENTS : pe , , o -� itk &kerma YC3yj& ® r tM (�-'C C C ' I 4e rx f�D Ct 1 <br /> I ereby certifY that I am authorized ro complete this application and that the work will be done in accordance with <br /> �S aq n ounty Ordinance Codes and Standards , and all other applicable California laws . <br /> Signed Title/Company ' l-I` y-�-� \� - <br /> Print Name L � Date L <br /> EPARTMENT USE ONLY <br /> Application Accepted By : Date Issued : > ' I Z o <br /> Grout Inspection By/ Dates : <br /> Destruction Inspection By/Dates : <br /> Facilit /Site Information <br /> FA Name U� fc , Ce a �-� FAAddress 7 FA# t? Q ��I C # 0 (� <br /> FA PE WP Reviewed By W Work Plan Date /2D / <br /> [jC-57C-57 Authorization for Other to Sign Permit ❑ Worker's Comp El Worker' Comp Waiver Encroachment Permit ❑ Access Agreement El Lead Agency Approval r FR 1 <br /> COMMENTS/CONDITIONS : Q t^ <br /> L Is <br /> & u YVK n ton <br /> r <br /> WP TYPE PE SC FEE INFO AMT REMITTED C(( /HECK# RECV' D BY DATE �, r W LL P RMIT(#� INVOICE# <br /> Permit " 1 $ 152 x V ! - 51� " V 1I <br /> 41 <br /> 1868 E . Hazelton Avenue ( Stockton , California 95205209 46&3420 F 209 464-0138 1 ww. sjcehd . com <br /> T w <br /> EHD 29-01 08-01A7 /1 /� / 24 Q � O / cm Site Mitigation Well Permit Application <br />