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N a a Q N Environmental Health Department CUUI�,ITY Greatness grows here. 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 Jo qui County Development Title C pter 9,a,115.3, and th�S n J aquin County Well S tan dard Job Address x . City tate/Zip � Dcl4Lt'sA hfV , Phone Cross Street T r9( APN —\6 Property Owner* Q�Mt—cck Phone Address City/State/Zip ail" (.� �oLj Oct", ��( License# ��A�Oy Phone��y�yb>�(`� C-57 Contractor Y Y\Q Address \\$b &Lkt, \nu \ City/State/Zip ('nu_l 1,CA gsjlj2 Consultant/Sub-Contractor&\\,ixw ku�Y�� 7y0(,cc�"�('�, License# Phone��b��j�2' Address-&% �� 2�1cstCG� City/State/Zip \oe Ir,aV1e _ q an\ CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING HOLLOW STEM BORING DEPTH O ❑BOLTED TRAFFIC BOX ❑STOVE PIPE EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE r ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:'STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: L% Casing Depth: ❑ INJECTION(Air Sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE;PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs ?\ 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 q PIPE ❑MUSHROOM CAP El❑3 feet below surface _or n n feet below surface if>3 feet COMMENTS: Neel-� �'�iWti-�� L i � Ci�f �� i at r Cx . � Reu LV 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 others applicable California laws. tU Signed ~�j Title/Company - �" � V A. CW'cti��fi(P KlY1` �ff�il9C W�j Print Name �-7 Date N I-7 11 2 DEPARTMENT USE ONLY � �O � 1 i JApplication Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name I�,�Q, FA Address FA# ��j �-f-� !�� PR# ✓ 7 v�7p FA PE WP Reviewed By ) (/\� Work Plan Date lZ 0 ❑C-57 C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver l❑/Encroachment Permit ❑Access Agreement ❑Lead Agency Approval FR COMMENTS/CONDITIONS: '5 LA /I I� re v I&Wl �,2 / WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 611001 DU 5 U 1868 E. Hazelton Avenue ( Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 SR-vg 3S Site Mitigation Well Permit Application