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q. r SAN JOAQUIN COUNT)' <br /> ? ENVIRONMENTAL HEALTH DERIIFTIN NT <br /> 1868 Hazelton Avenue, Stockton, CA Pi' I 232 <br /> Telephone:(209)468-3420 Fax:(209) ,$68-3433 .'Ab.' sicehd.com <br /> JFO <br /> SITE MITIGATION WELL & BORING PEVNIIT APPLICATION <br /> For Wells and Borings Used for Contaminant Invest gations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FW:N DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to constru:I a td,or install the work described. <br /> This application is made in compliance with San Joaquin County Development'ritle,Chapter V1,11 3,and the San Joaquin County Well Standards. <br /> Job Address ressrcmemy.rwgtzwsz city/State/ZIP Lamrt:,cn s53:o Phone <br /> Cross Street Nene wev <br /> Property Owner• eu tes=ac.rmmao, iieswvm,maer (Cern _Phone I9im3rs3sao <br /> Address 8815 EHx CreN emtl f TI Ik{ r /eft <br /> 71v, ,jCA ! r VEOLIA _ <br /> C57 Contractor �n wa aanm,v„em lrvrar) CA 91 <br /> Phone 1916)38}9]55 <br /> Address 33 nira. m WATER _ <br /> Consultant/Sub-Contractor Hnr, . t- Phone (sw)rss•24en <br /> Address 2e27apeemds <br /> YYY �tL3SAnI <br /> CONSTRUCTION WORK TO BE PERFORMED-*No rchment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE �!,/. <br /> O MONITORING z NI HOLLOW STEM 7 ���� ISTOVE PIPE <br /> ❑ EXTRACTION(Vaparlwater) ❑ HAMMERIDRIVEN EL WELL CASING DIA<" <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY ❑ OTHER <br /> ❑ SOIL BORING El PUSH POINT(GPI CPT) Casing Depth: <br /> ❑ INJECTION IAi Soame.Omer ❑ HAND AUGER RS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: <br /> WELL/SOIL BORING IN KMw-ia.Kraw-n www.vQ <br /> oliawaternaxorn. <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION MErHgn_crEcnHLL APPLY) <br /> #WELLS TO BE DESTROYED i ❑Q OVER-EORE DIrMIETI:R of.0.5 inches to depth of 31 feet <br /> WELL IDs iorwa [I PRESSURE GROUT T: leplh of feel below surface <br /> GROUT SPECIFICATIONS mmmmmr ❑EXPLOSIVES Fan _ to feet below sudate <br /> COTHEMM TYPE: BE USED ❑AUGERS ❑HOSE N PIPE ❑MUSHROOM CAP E; 313e1 xb surface or feet below surface if>3 feet <br /> COMMENTS: '" —' <br /> hereby certify that 1 am authorized to complete this application and that thil-w)rli wit be done in accordance with <br /> San -a alIn Ordinance Codes and Standards,and all othh.:applica le California laws. <br /> Signed Title/Company miweop_:.e.m,-em <br /> Pri ame �1P,1-/4 �. S1 C2 o'(�,_ Date 'I_�- \ <br /> i <br /> �� / DEPARTMENT USE ONLY <br /> Application Accepted By: 41'e T/Prs�/�'®/mss" rale lnsu �� //S <br /> 7 <br /> Grout Inspection By/Dates: <br /> Destruction inspection By/Dates: <br /> Facili /Site Information <br /> FA Name - FA Address ,_EF#. PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑G-57 ❑C57 Authorization for Orer to Sign Permit ❑Workers Comp ❑Workers Camp Waiver ❑EncmachmeH 3ei nit ❑ cess Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: ---' <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV•O BY nF TEE : SERVICE REQUEST# INVOICE# <br /> Work Plan 29p3 $23 -� 39c �' 390 �03g CPV !/-�/f s<t' 007 60 <br /> Permit 29v1 3l1 $130X 2_ 2E r 80383��f' S'/20 073 7 6 ( <br /> Z9UZ 31-6 00 Ss030 C/Vr(� "/3c//` 5'k00737 Z <br /> EHD 29-016-23-2015 <br />