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SAN�JOQQUIN Environmental Health Department <br /> COUNTY <br /> =ltlrol„ol 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 ZO A-) <br /> 48 Hours Advance Notice Required For All Inspections `-F 68 — O 33,5 <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 9-11115.3. and the San Joaquin County Well Standards. <br /> Job Address 2605 5. fAoZ kf- In it nr. Clly/State2lp Trol cv r CA '153-1 ( Phone Yle <br /> Cross Street Valpico Rood APN 2q6 - /`/ O — /3 'b <br /> Property Owner' V o 1 pi co A pa0me.rYt S , lrL(. Phone <br /> Address t2oO N C4landy Dr . City/State/Zip L-os CA rxl+q <br /> C-57Contractor TEfT - por+VNe-Tn California r Inc License# 0 to 5 (o P) Phone 6I110 - A53 - 8 10 <br /> Address II3S6 Monier Park PIaGP City/State2lp RaTnCKd CordOyo, ,_GA g6 �q'Z <br /> Consultant/Sub-Contractor LC.I!�h+On and Ls%OCj 0,4CS , In(License# Phone '14q- Zr70 — I I•IZ-I <br /> Address i-1"1A1 (.owo,n citylstatelzip Irvir\e- , CA 617-WH <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: OBsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH S1 $ I.Gi 1 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporWater) ❑ HAMMERIDRIVEN OIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> 19 SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING K PUSH POINT(GROPT) CONDUCTORCASING ❑Yes ❑No Bering Dia: Casing Dia: Cosing Depth: <br /> ❑ INJECTION(mamoe.ozone) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ON, <br /> N Nde:Mssknum Free�fe/l,l D/e]eIh is 30 Ft) <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS �W,4m /(,a 1 z--r ah-')zz S <br /> DESTRUCTION WORK TO BE PERFORMED: DE RUCTION METHOD: CHECK ALL THAT APPLY ��JJ�� �C <br /> #WELLS TO BE DESTROYED OVER-BORE DIAMETERof inches to depth of_r�feei (,Up <br /> WELL IDs []PRESSURE GROUT To depth of feet below surface 1 <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [:]AUGERS []HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface B>3 feet <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 /> San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed ?? wy,/ Title/Compan Srocl/ 7 ! 6/oLu6(f'/ <br /> Print Name PoSf f(n ry�r11(Cy Date � �2l 12U 20 <br /> DEPARTMENT USE ONLY /' / � 2 O <br /> Application Accepted By: �� Date Issued: � / <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Faclll Slte Information <br /> FA Name V�� •t 5 FAAddress bs S Fj C,Car� FAR 00 Z57 PR# p <br /> FA PE 111 P Reviewed By ode Plan Date <br /> ❑C57 57 Auassha0on forOther to Sign Permit ❑Workers Comp ❑Wokers Comp Waiver ❑En roadun nl Permit ❑AccessAgreemeni ❑Lead Age Approval ❑MFR <br /> COMMENT ITION : l>yt Mtl copy [>� " —I r •("a { W fi+ -V re 2.qf Q <br /> WP TYPE I PE I SC FEE INFO AMT REMIYED1 CHECK# I REcAro BY I DATE I WELL PERMIT# INVOICE# <br /> Permit IZOP5 3 3 $152X 3 N — 5 04 128 0 0 5D <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 1 www.sjcehd.com <br /> EHD 29.01 oa-01-17 She MIUguon Woo Penh Applke0on <br />