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SAN JOAQUIN Environmental Health Department <br /> COUNTY - - <br /> �,4'rllrt 5� ,ir r.6 iiri ( <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION RECEIVED <br /> For Wells and Borings Used for Contaminant Investigations and Remediation JUL 1 Q 2019 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor 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 Q�Bs e hOy' %J'+ �N . City/State/ZipJ1 aC�-�o.,, � A aSZOf Phone <br /> Cross Street pt� I • APN 0" <br /> Property Owner' IVP^c SA^ �/rttl"[:� If.1 - Phone <br /> Address bi l6j G L-f -o f-n . Chylslate/zip rAA6te(A,[4 A5336 <br /> n <br /> C-57 Contractor Y tnt �arL oco'.' I nt , License# 61 N 8 9 9 Phone �3D blot 3 b oD <br /> Address 220 Al E05;} SF . City/Stata/Zip W014(e14, (A n$171, <br /> ConsultanUSubb-Contractor (✓` y^t P(1/4 r (rl - License# 3VO3y s Phone 1 (4 W2b o' Z <br /> Address pill A•f . City/State/Zip adfAS 44-, CA clo6u <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: OUsHe Smings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH NS0 e ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMatet) ❑ HAMMERJDRNEN DIA.OF BOREHOLE J-`t ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS — TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> M SOIL BORING 3 19 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes Bit No Boring Dia: Cmkg Ds. Ca4ng Depth: <br /> ❑ INJECTION to sera.ozwl ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED []AUGERS []NOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? RYes ❑No (Note:Madmum Freels]Depth is 30 Fl) <br /> WELL/SOIL BORING IDS 06, V, a $ GROUT SPECIFICATIONS N<"f Lfz-fpt <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of—inches lodepth of feet <br /> WELL IDS ❑PRESSUREGROUT To depth of_feetbelowsudam <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to—feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE Q PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feel <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> v- � .A S7 Joaquln County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �1 PI Title/Company__5}q�F� <br /> Print Name S�`^•'I �P��ID I� Dale —1-3-'� l � � 'I / 6 <br /> Application Accepted By: ,Y��rf/1 DEPARTMENT USE ONLY Date Issued: 'l� f t y� ! Z 0 1 <br /> Grout Inspection By/Dates: —�� / <br /> Destruction Inspection By/Dates: t r _ �"r �. 7 --y� <br /> acllil /Site Information <br /> FA Name ro/ntltr Shell Seillat 7NT FAAddres$ ZO$sj 5. MQvi OS•A, FA# <br /> FA PE Z q 6 v WP Reviewed By Work%an Dale <br /> ❑G57 N1057Authorizabten for Otherb Sign Permit 54sesoornp ❑WorkeesComp Waver ❑Enwerhment Pe A ❑Aaess AgwrrerA ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE I PE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# <br /> Permit 2905 313 s,SzX 3 13g415 J'(A1 I =l­/1- i WPO03 'il935- <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> END 29,010"1-17 $Ne Miegedon Wei Permit Appkuaon <br /> 7-llo3 5 752x3 45L is°i4lS 'SuJ V%1/1" SRGog0" <br />