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'OO <br /> / paUlty{ <br /> f= -- S A N .10 A Q U I N Environmental Health Department <br /> COUNTY <br /> 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 <br /> )in compliance with San Joa um County Development Title,Chapter 9-1115.3,and the <br /> San Joaquin County Well Standards. <br /> Job Address -7 r 7 W /T I bka� ,, ��iE'_ City/State/Zip j r C1:1 <br /> Cross Street I AN e 11 APN // //// <br /> Property Owner* G 1Gi(e- i.,�Cr P)C C,Rhone�I Z37, 7 C�/'7 <br /> Address 1✓' : L City/State/ZipLA"re <br /> C-57 Contractor n_ License# 7—In 9 C) Phone ZC� ! 6 CJ, 77 DC <br /> Address ( Zj' I`c c - ; City/State/Zip 31— <br /> Cons ultant/S u b-Contractor <br /> 1 - <br /> Consultant/Sub-Contractor (' r License# ( - ppr �Z�j Phone 2 (I <br /> Address (AZ City/State/Zip �"R���L 1.. CA 9 <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) ❑ HAMMER/DRIVEN 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 �p <br /> El OTHER El OTHER: GROUT SEAL PUMPED? El Yes El No (Note:Maximum Freefall Depth is 30 Fl) PAYMENT <br /> MENT <br /> WELL]SOIL BORING IDs GROUT SPECIFICATIONS RREGEIVED <br /> DESTRUCTION WORK TO BE PERFORMED: L DESTRUCTION METHOD:(CHECK ALL THAT APPLY) MAY 10 2021 <br /> #WELLS TO BE DESTROYED_ 0 Ll( � ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDsPRESSURE GROUT To depth of 0_�5 feet below surface SAN JOAQUIN COUNTY <br /> GROUT SPECIFICATIONS ❑ XPLOSIVES From to feet below surface ENVIRONMENTAL <br /> %LTlit D .PARTMENT <br /> TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE El PIPE ❑MUSHROOM CAP El feet below surface or feet belo cel > eet <br /> COMMENTS: <br /> /Rereby certify that I am uthorized to complete this application and that the work will be done in accordance with <br /> San J qu' ounty Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed f7. Title/Compan �° - � — r <br /> Print Namec< G Date ( 12-6 <br /> )_,,2(EPARIITMENT USE ONLY <br /> Application Accepted By: Date Issued: (/ <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA NamebAl- <br /> t`LI CIS Q f� FA Address �j� ����,,,/� FA# � � o 16�$� <br /> FA PE WP Reviewed By v Work Plan Date V <br /> ❑C-57 ' C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval FR <br /> COMMENTS/ ONDITIONS- 1 i j f ^' `j }-1 `^ ; y� <br /> \� 1. <br /> P �. <br /> WP TYPE PE SC FEE INFO AMT REMITTED K# RECV'D BY T WELL PERMIT# INVOICE# <br /> Permit Z (22- -.3( $152x ` �) (9v <br /> 1868 E. Hazelton Avenue Stockton, California52�0p5 ( T 209[468- 420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 / 'tom ��� O 1 l ,I 2 Site Mitigation Well Permit Application <br />