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SAN JOAQUIN COUNTI' • RECEIVED <br /> AAUIk <br /> ENVIRONMENTAL HEALTH DERI�FTINENT NOV 18 2Q15 <br /> a: < <br /> '• 1868 Hazelton Avenue, Stockton, CA f1520:`.i-6232 ENVIRO <br /> gTrddaN:P Telephone: (209)468-3420 Fax: (209)468-3433 ,ViEb.www.sicehd.com PERMITSERVIC gITH <br /> SITE MITIGATION WELL & BORING PERhirr APPLICATION <br /> For Wells and Borings Used for Contaminant invest ]nti os and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRI_N C.A E ISSUED <br /> Application is hereby made to San Joaquin County for a permit to cOnsW:' a Td7r msta� II the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter:+ 1 15.3,and the San Joaquin County Well Standards. <br /> Job Address 19m7cmem wa (6 n City/State/Zip umnr_cassc.o Phone <br /> Cross Street N.m•w•y APN isa-1Ioae <br /> Property Owner` am omn LLQ a Cafoda■ndad babmn cvraPaM (u`Im T.VEas9W1 Phone eslelrr m <br /> Address e015EW.CmkR d 1 <br /> •2er 1S�i'rcw.LwdAt RPv F•+ Fl✓Krt+I, <br /> 78 V, GwL(.i,q_City/State/Zip saw_.,+¢a.ase e <br /> 9 S33U <br /> C-57 Contractor Ak we aeva9ne.n IfiFB 64„t4lG.u�g� License# ase359 Phone talsPaa92ss <br /> Address 33a9Fd¢9 Ide d Cfty/State/Zip sti my,cA 53mit <br /> Consultant/Sub.Contractor ey� I.. License# Phone t530l 7sa24e4 <br /> Address 2e27Srarto,d Sb t City/State/Zip D.k::ksew <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Acce r.A gn:a encs or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH _❑BOL ED RVTIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water( ❑ HAMMERrDRNEN DIA.OF BOREHOLE ❑MULI PLI CISINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE Q MUD ROTARY CASING THICKNESS TYPE O,' IA;IN': STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING Cl PUSH POINT(GPI CPT( CONDUCTOR CASING ❑Ye:: ❑No Bodng Di;: __ Casing Dia: Casing Depth: <br /> ❑ INJECTION iA,swma.0. ❑ HANDAUGER GROUT SEAL DEPTH TREMIE I'PE TO BE SED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:M..:mu n FINfal Depth is 30 Ft) <br /> WELIJ SOIL BORING IOs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METH(;-I):LttECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED + 9 OVER-BORE I „M-T:R of 0.5 inches to depth of 31 feet <br /> WELL Us ivaw-1 ❑PRESSJRE GROUT Tu de)th 7f feet below surface <br /> GROUT SPECIFICATIONS EXPLO:)IVES Flim to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS El HOSE N PIPE El MUSHROOM CAP [.13 bet bewsurface or _ feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that tt- Aork w III be done in accordance with <br /> M4001 manes Codes and Standards,and all ott er Ilpp ilc bie California laws. <br /> Signed � } Title/Company Au wet 2>a,dan,am <br /> Prinlr�ama---' Date— <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: /V�e� f7Cv�Gj�SO� Da.e iss'ed: <br /> Grout Inspection By/Oates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address ._L°AII PR# <br /> FA PE WP Reviewed By Work Pian Date <br /> ❑C-57 ❑C37 Audmblion k s Ober to Sign Perm t ❑WaWs Comp ❑Workers Comp Waiver ❑Encroachinv'PeTni: Access Agreement ❑Lead Agenry Approval ❑MFR <br /> COMMENTS/CONDITIONS: - <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit '290 Z- 313 $130x I $"(30 $039 CAI7Z 5R,0073763 <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />