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M <br /> S A N 10 A 0 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 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address Sea mwc,pt,roort Art E City/State/Zip teeaop.eAQm Phone HA <br /> Cross Street ASUWe FntM ... APN +sse of <br /> Property Owner` u.s.oaP• idma" Phone m+-2424+se <br /> Address u.s.A"Gaasa„P,�aMonm,ayo:e iedP wan,P.o.ex: CitylState2ip nwaa,.y.rA sow <br /> C-57 Contractor caMaa Dom.LP License# maim Phone 91041a0a59 <br /> Address +2os.2aasL City/State/Zip ma nd.c New <br /> ConsultantiSub-Contractor Anna End,maenx+4 we License# wA Phone em3sscoos <br /> Address 2e55cmo-acom BWSW312 City/State/zip P ..t M.CA"M <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offete Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTEDTRAFFICBOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapaMafer) ❑ HAMMERMRIVEN Dui OF BOREHOLE ❑MULTIPLE CASINGS❑MULTILEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dim Cwhv Die Casing Depth: <br /> ❑ INJECTION NN spare.owes ❑ HANDAUGER GROUr SEALDEPTH TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nola:Maximum Freela7 Depth Is30F0 <br /> WELU SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED Two ' I]OVER-BORE DIAMETER of 10 Inches to depth of 26 feet <br /> WELL IDS Mw3ae and w4 ❑PRESSUREGROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS cement l,eaonaapwl - [I EXPLOSIVES From to i feet below surface <br /> TREMIETYPETOBE USED ❑AUGERS ❑HOSE XPIPE ❑MUSHROOM CAP M3feetbelowsudaceor 0.5 feel below surface if>3 feet <br /> COMMENTS: <br /> 1 reby certify that i am authorized to complete this application and that the work will be done in accordance with <br /> Sap,lo In County Ordinance Codes and Standards,and all otherIapplicable California laws.. <br /> Signed /� t�v✓' Title/Company mn EnWan w.wersLGwwgKP,apammam w <br /> Print Name samelxaa.Pc Date segsmarm,sort <br /> EPA T E USE ONLY <br /> Application Accepted By: � Date Issued: A�U3 "] <br /> Grout Inspection By/Dates: <br /> Destruction Inspection BylDates: rA+F.w315jk1 Mvi-Ag ( UX L;eII. Ir'I <br /> Facili /Site Information <br /> FAName (""—I at FA Address FA# �ZUL PR# � Z <br /> y a <br /> FA PE `j-'-1 b2L? WP Reviewed By . �( Work Plan Dale r <br /> ❑Cb7 W15VAUthorustiontorothertosignPonrit M16keescomp ❑workeescarpwaver ❑Enaoachment Permit ❑Access Agreement EgfeadAwgyAppmal ft}gR <br /> COMMENTS/CONDITIONS: <br /> JVVPTYPEJ PE I SC I FEE INFO JAMT REmiTTED1 CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit "aL 313 $152 x Z 3 n L6 i L.X t 1 <br /> o) -7 \N P Do ' 3-1 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 I www.sjcehd.com <br /> EHD 20 01 08 01-17 Site Miagelicn Wet!Perini ApplimUm <br /> wC -vlu3 If5 Z-x cu,%� 7 sPVO 7f"if <br />