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06" SAN ���10 AQ 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 in compliance with San Joaquin County Development Title , Chapter 9 111 3 , and the San gayui County Well Standards , <br /> Job Address City/State/Zip C C' C - G � JJ SSPhone AM t1 <br /> Cross Street W , ' � �l APN � Z © L ���, L 34/ yD 1 <br /> Property Owner CGS w c Phone?. <br /> Address 1 ' City/State/Zip /106W eC J <br /> C-57 Contractor *r � A'k 5 ,27AC nse# Z ©`9l C n Phone LC <br /> Address 3f? c AA J - ' •C% ty/StatelZip fT C/ T s � L- / <br /> Consultant/Sub-Contractor y� License# 6101 Zycj PhoneZ01, 2460 <br /> Address 7 — Y 1J , City/State/Zip S� pc �i �(, / a V��o(o <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 WT <br /> PIPE <br /> ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 7 // ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS — Amk 1 / TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: f� Casing Depth: Z <br /> ElINJECTION (Air Sparge, Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: I:] AUGERSVf HOSE IPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Yes ❑ No (Notp: 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 ❑ 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 El AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP <br /> � EL feet below surface or feet below surface if >3 feet <br /> COMMENTS : Pf��'g1e 'f 4t tlokvv -,fre , 0 r, JL D-'CC /1 I`/_`2 f 4 00f <br /> 1 R" eo �— `,ji b � k " l tCei �iCIA 'L1� f'r u trI! � vtSL , <br /> I ereby certify that I am authorized b6 complete this application and that the work will be done in accordance with <br /> aq n ounty Ordinance Codes and Standards , and all otth_er applicable California laws .li <br /> Signed Title/Company ' <br /> Print Name rC L S Date <br /> EPARTMENT USE ONLY <br /> Application Accepted By: �� Date Issued : I C) 2 ' <br /> Grout Inspection By/Dates : <br /> Destruction Inspection By/Dates : <br /> Facilit /Site Information <br /> FA Name Vk j2in ( T CQ Ap4r�4*4w FA AddressFA# # 7 WOO <br /> c� S3 <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑ C-57 A.C. 57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker' Comp Waiver Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval FR <br /> COMMENTS/CONDITIONS : /mat U� /d () i51q// <br /> L <br /> 1�e C4 LA <br /> WP TYPE PE SC I FEE INFO JAMT REMITTED1 CHECK# I RECV' D BY I DATE W 9LLLL P RMIT# INVOICE# <br /> Permittq 0 � $ 152 x <br /> 1868 E . Hazelton Avenue Stockton , California 95205 ( T 209 468-3420 F 209 464-0138 1 www. sjcehd . com <br /> EHD 29-01 08-01 -17 /1 4 �/� / 24 Q30 <br /> / Site Mitigation Well Permit Application <br />