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SANJOAQUIN Environmental Health Department <br /> .r....: <br /> COUNTY <br /> "a,,, „r;, 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 SanJoaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 3Ot3( 50 -� Wl&r PA,-y City/Statemp IrMM (�t/1,gS377 Phone It3L-V-7- HOCj <br /> Cross Street we :nn APN 2.5 I'30 - 2°� <br /> Property Owner' JLwA N fZLsa 2g Tf")4 F,+Al Phone <br /> Address ti q I�,LI Co/� (.F CltylStatelZip S}Lxk}p,� 1 (A �j5'LO'7 <br /> C-57 Contractor Efx.' 11 e br`Ik •" License# 105', ?J3 0 Phone 510-';(oL-Z411 <br /> Address Swo D Aook 4, City/StatelZlp wo-Ek q 5r oq k <br /> ConsultanUSub-Contractor GHn SethiLt-S (AG- License# S55 'L710 Phone kl(O` 6(oS-ogZ� <br /> Address 91-(3 /Zeservt•- yr, City/StatelZip (Lose-J (je Gt4 95(o"75S <br /> CONSTRUCTION WORK TO BE PERFORMED: `Note: OUsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I�q+ MONITORING �_ HOLLOW STEM BORING DEPTH 160r ❑BOLTED TRAFFIC BOX STOVEPIPE <br /> LJ EXTRACTION(Vapor/Water) 0 HAMMERI)RIVEN DIA.OF BOREHOLE 0 " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS , `4C' TYPE OF CASING: [I STEEL 1APVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dla: Gazing Depth: <br /> ❑ INJECTION 14 Sea'ae.Ozone/ ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: NALIGERS [I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 6(I Yes ❑No (Note: am Freefal Depth k 30 Ft) <br /> WELD SOIL BORING IDs _BUJ-'S GROUT SPECIFICATIONS PmrkLt ArA <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) <br /> #WELLS TO BE DESTROYED i ®OVER-BORE DIAMETER of_10 inches to depth of 16-feet <br /> WELL IDs MW-3 ❑PRESSURE GROUT Todepthof A)A—feet below surface _ <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE El MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet <br /> COMMENTS: Tk C4&6`A5 C(,^ be- QA- ()rVIAC r 'tlir vsok let C1\ C-t-AISl41(¢d- <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 Callforni laws. <br /> Signed 'E� Title/Company A\4d 2;k& T �7if <br /> Print Name i�2Vr4rJ SANOo2, Date 12'2'1q <br /> -,DEPARTMENT USE ONLY / / <br /> ,A �ppplication Accepted By: Date Issued: o2 <br /> r—"1Gro r R ection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name % I'lG r Address I <br /> © ' S- �4,elr&rl FA# 0b PR# .P <br /> FA PE l• G) WP Reviewed By �� Work Plan Dale <br /> ❑C-57 <br /> T. G57Authodzalbnfw Otherto Sign PemN ❑Workers Gomp ❑Wodeers Gump Waiver ❑Encroachment Pemiil ❑AcceassAgreemenl [I Lead AgencyAppmval ❑MFR <br /> COMMENTS/ ITIONS: 0 /_- , ^� >/, 5 �`�-- rp,OQ�f PQr1M�'� (sre <br /> U <br /> JWPTYPEJ PE I SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 2g13 3 $152x (,j 2 IZ <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-6138 1 www.sjcehd.com <br /> EHD 29-0108L1-t7 Site Magellan 6a <br />