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RECEIVED � VNC - S A N-J O A Q U i N Environmental Health JAflMW gent -C O U N T Y- ENVIRONMENTAL HEALTH \ Greatness grows here. PERMIPSERVICES 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 kthe San Joaquin County�WeellgStandards. Job Address �JO YIL Yt� City/State/Zip��lzV-TafJ CA P one !D q(? C `+ I: Cross Street 1 APN Property Owner* �('�Gj 1'��I y Phone a-q/9 y(P-C 2SI-(o Address Z2-� j[J��t� lI 1 ,?�tJ S I City/State/Zip' �i CAS q5--)-0- C-57 Contractor 2i�t'a4r- 1J License# I)OLec,019 Phone 6 W/LOU(' 3�v Address -0 14. Ah 11 '5r City/State/Zip ConsultantlSub-Contractor Phone �31p"30.3 Address I�1� � 1 � City/State/Zip n 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 ✓„ ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes C�No Boring Dia: Casing Dia: Casing Depth: INJECTION(Air Spam,Onne) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS HOSE ❑PIPE ❑ OTHER OTH R: GROUT SEAL PUMPED? Q Yes ❑No (Note:Maximum Frr"llll Depth Ft) WELL/SOIL BORING IDs el a GROUT SPECIFICATIONS yam- t— o� 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 surface if>3 feet COMMENTS: I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with n Joaquil Clounty Ordinance Codes and Standards,and all other applicable California la s. Signed I;b1 (t 1�C Title/Company`s It ! ',x; I`Dt K L r-�l C Print Name �� 1� Date 'h'1 \. Application Accepted By: DEPARTMENT USE ONLY Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili / ite Information FA Name fo%l1 a� h FA Address FA# ��• PR# 62t:igia FA PE WP Reviewed By i Work Plan Date V �a ❑C-57 C-57 Authorization for Other to Sign Permit (Z'Workefs Comp ❑Workers Comp Waiver []Encroachment Permit [:]Access Agreement 63fead Agency Approval 04915R COMMENTS/CONDITIONS: WP TYPE PE SC2 FEE INFO AMT REMITTEDCHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2AOQ{ 3 i 1 $152 x ' /- L. -�)( 1 1 1 M Wo 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Wei Permit Application vj P Z413 5L3 4/SZX �lS 2-3a L--� ►/91101 59-0=�-7 Z