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• � 1 <br /> I <br /> I <br /> ;., SAN JOAQUIN COUNTY <br /> r , <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT <br /> t 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remedlatlon <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct ardor install the work described. <br /> This application Is made In compliance with San Joaquin County Development Title,Chapter 9.1115.3,and the San Joaquin County Well Standards. <br /> Job Address /� i✓r CItYlStetarllp ,S?�/ �� �SZ03 ne 7n!1-yf do-CSI& <br /> Cross Street Onzil elyCd(fL APN <br /> Property Owner* Phone :77,0-0� <br /> Addresc CitylStale2lpr7re�ie'"W00-- 0/Ly)/Ll.� <br /> C•57 Contractor Licenses 013£3110 Phone�l9/4— 630V/l <br /> Address a I, ��'�eltylState2iPV' r,4,�4fa Me,1�0,a 7lcw <br /> ConsultanUSutHContractor C- T p.S= Wb4,� 6PTucarea s y Q��I n Phone 1-7 <br /> Address I r 70 -ole ♦'71, �',�rCr6T4,p IlC l CltylState2ip )9 )QLu.50, 1�!j <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringaNJells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORINO NUMBE INSTALLATION TYPE CONSTRUCTION SPECIE AT <br /> O MGNtMFUNG ❑ HOLLOW STEN BORING DEPTH O BOLTEDTRAFRC BOX ID STOVE PIPE <br /> O EXIRACTION(VswJWaler? _O HAMMERVORIVEN OIAOF80REHOLE /' ❑MULTIRECAS"-NGS O MULTH.EYEL WELL CASING OIA <br /> O SOILVAPORPROOE ❑ MtiDROTARY CASINGTHICXNESS TYPE OF CASING: [I STEEL EI PVC OOTHER <br /> E �� MT <br /> SOILGORING ' PasHPO (GP+cn CONDUCTOR CASNG OYa ❑ 7//No Bedre0la: Casbp Ola: aIng Deph <br /> NIECTION(as,"o.m.) _O HAND AUGER GROUT SEAL DEPTH TREND TYPE TO BE USED:A AUGERS O HOSE O PIPE <br /> ❑OTHER ❑ OTHpFJL�� GROUT SEAL PUMPED? 99 Ym O No (Note:Malmum Freelai Dep)Is 30 PO <br /> WELL!SOIL BORING IDs � yagn GROUTSPEGFTCATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:iCHECK ALL FIAT APPLY? <br /> N WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Indies to depth of_Let <br /> WELL IDs ❑PRESSURE GROUT To deph of_feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSNES From_lo_feetbelow surface <br /> TREMIE TYPE TO BE USED Q AUGERS ED HOSE 0 PIPE Q MUSHROOM CAP ❑3 feel below surface or feel below surface If>3 feel <br /> COMMENTS: <br /> harebY eo Y sbE .x6d to Ign �tltlW an 0. wIIBlbe do rrAed'o T , <br /> _ .. �. . .... ..�:3. .. .GIlta> i"aCa1lIL.�SIaJats._ ^4....` <br /> Signed ntwcompwy rd JC0_0&_ <br /> Print Name A', ke, /d 7 G 0. Dale__ <br /> DEPARTMENT USE ONLY /) <br /> Application Accepted By: U V.J y��( Data Issued: <br /> Grout Inspection By/Dates' Z <br /> Destruction Inspection By/Dates: a rH:"`' `-� 1�/ w a ♦& r< '<r <br /> Facilil /Site Information h/or'(' lirv� /t�>✓<-� Z�♦♦ //. <br /> FA Name FA Address FAs PfTs <br /> FA PE WP FWmad By I I Wank Plan Oats <br /> C57 O657Auft&ztIcnbrO#wIo Spn Pemtll rkera Comp ❑Workers Cory Waher ❑E=advr IParmN OAoxss ApaemeN MGad Agency Approval R I <br /> COMMENTSICONDRIONS: 61"'14bnryn5.r 6dr7y'P"'O,a C.;L1 eC ( Neat-, Sl <br /> I <br /> SR TYPE PE I SC I FEE INFO JAMT REMITTED bHIECK#I RECV'D BY DATE IkSERVICFRrOUftST# 'INVOICE# <br /> Pem,lt, 790Y 1313 180X 3 'I f 3)0 P&Pfl 'L"4X— I 15A(/07W/ <br /> MC- <br /> I <br /> EHD 29-016.23-2015 Site MlUgalion Well Permit AppllcaVon <br />