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gC3U11V <br /> • ,J � AN 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 witkSan Joa uin County Development Title , Chapter 9 - 1115 . 3 , and the San Joaquin County Well Standards . <br /> Job Address City/State/Zip Com:' 6 3 Phone <br /> Cross Street 1 yy 11 APN � 6 f <br /> Property Owner* 1.., � C =— l,{j L, c �hone2l-� 1. 3 �, 7� Iq <br /> Address - u ' � City/State/Zip � � � % Ck C1 <br /> C -57 Contractor n _i License# Z-. C� Phone '2, c 5, T <br /> Address i ?j 1 C, t -r V City/State/Zip j e2- <br /> Consultant/Sub-Contractor (' License# ( �� ,- r' � �j Phone �s <br /> Address $ �l �• �, I City/State/Zip � � 1L •1�. , C Sb� �� <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 <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ElYes ElNo (Note: Maximum Freefall Depth is 30 Ft) PAYMENT <br /> WELL/ SOIL BORING IDs GROUT SPECIFICATIONS Ing P► >� 8® / l� <br /> DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) MY 10 2021 <br /> # WELLS TO BE DESTROYED . . Li OL 10 ro i� ❑ OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs PRESSURE GROUT To depth of feet below surface SAN JOAQUIN COUNTY <br /> GROUT SPECIFICATIONS E:1XPLOSIVES From to feet below surface ENVIyyRppOENNTAL <br /> P RTMENT <br /> TREMIE TYPE TO BE USED El AUGERS ❑ HOSE E] PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet belovA% e if > 3 feet <br /> COMMENTS : <br /> /Lereby certify that I am uthorized to complete this application and that the work will be done in accordance with <br /> San JJ quounty Ordinance Codes and Standards , and all other applicable California laws . <br /> Signed i' , Title/Compan C �' alb <br /> Print Name , <. Q Date W72L6 <br /> PARTMENT USE ONLY <br /> Application Accepted By : Date Issued : I <br /> Grout Inspection By/Dates : <br /> Destruction Inspection By/ Dates : <br /> Facilit /Site Information <br /> FA Name 0 � j� C IqApm4 FA Address � t 7- U� ' FA# t! P 6 , D T6 <br /> FA PE ; WP Reviewed By Work Plan Date <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 4AMFR <br /> COMMENTS/ ONDITIONS : � � i �U Cj / \Aj <br /> too =` r <br /> rvA <br /> WP TYPE PE SC FEE INFO AMT REMITTED K# RECV' D BY T WELL PERMIT# INVOICE# <br /> Permit Z �2 f $ 152 x 4i 0 q <br /> 1868 E . Hazelton Avenue ( Stockton , California 95205 ( T 209 468- 420 ( F 209 464-0138 1 www. sjcehd . com <br /> E H D 29-01 08-01 -17 /1 rP I *) C. l q I C, r )7;? Site Mitigation Well Permit Application <br />