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S A N ;] Q AQ N I N Environmental Health Department COUNTY s t SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin C�r S��II Standards. Job Job Address rq(n�,rk c�� i1�Y1 �F�C1rtL� City/State/Zip Phone ( '-y6 ) Cross Street Ahern 1'l�luC� \ APN � -CLk 7- �b Property Owner* LLt Phone Address ` City/State/Zip '�� A q •53 ON C-57 Contractor �) �kA_) 0 'A- -h , v'`( License# -]� t��lU�l Phone(7��ta y(�( --7 Address N\MVC\Ut�� (��I' City/State/Zip Cj& Consultant/Sub-Contractor Ce hj& '1\ �t4wk2.5 License# / Phone Address �Jo -\�rJ�Wt'�`�(ti� &1k�2\�ll'�L� City/State/ZipWc)t )ty2.{1'y1p,1 0 f CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING 1j HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE EXTRACTION(Vapor/Water) HAMMER/DRIVEN DIA.OF BOREHOLE �� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:it.STEEL ❑PVC [IOTHER SOIL BORING _�❑ PUSH POINT(GP/CPT) CONDUCTOR CASING❑ esY ❑No Boring Dia: Casing Dia: b Casing Depth: ?� INJECTION(Air Sparae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE rFIPE El OTHER ❑ OTHER: GROUT SEAL PUMPED? [I Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) / WELL/SOIL BORING IDs �j_ Qt� D GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE [:],PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surf ce if>3 feet y COMMENTS: �2'l L t `� �t v ( -� - �/ZOlzl I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. ^n ` A' Signed- Title/Company —ey' Print Name Date DEP TMENT USE ONLY Application Accepted By: Date Issued: 12-f Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name $Q„►-i� FA Address VV C �1 FA# PR# 57t f FA PE 0 WP Reviewed By ') Work Plan Date ii l ✓ 1 I ❑C-57 -57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval FR COMMENTS/C NDITIONS: ref �O C Li WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit {bl $152 x og6 2(009 4 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Sn 005/?" Site Mitigation Well Permit Application