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SA N MOM I Id Environmentdi Health Department -COUNTY- I! «.:' vreotness grows her SITE MITIGATION WELL & BORING PERMIT APPLI��ION For Wells and Borings Used for Contaminant Investigations an�t�x" fliROT8 18 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM SSIE1 48 Hours Advance Notice Required For All Ins Iections�,gR &,L q p EA7 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 the San Joaquin County Well Standards. of a 0 7 , t p r / C& 9saZ a Job Address /V j"II IA U/Q f.1 Clty/StatelZip /Yctt YYPZ^> Phone 2(9q-30^ q/�j Cross Street !a L1 n In 'I-' !nl 0 A-��V APN ©0.e-- /76 —/_ 7 Property Owner' E: wu p KA7 Phone M 9- 36Q- ple-k Address Po 136x /0 City/State/Zip ke-.4MPC2 ;�CA 2Z0 y - C-57Contractor (N6c?r>yj Ra 7QILL /N6 r LAIC License# C 5'7- 7/rr607g �T Phone �7-37T g3ab Address -<30 E� 7 enC((ty/Stat/-e/Zip Qt() UG ;+&- I " ConsultantlSub-Contractor-ltCp( ,-tJ G , A4v / e- CrCAku ri Llc�sse# CE6 7# / Phone 7-69- Address 'PC) 6OX /' '7 City/statelzip 0-OCb5le iri�C SJS` CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BodngsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPE FICATION I %,MONITORING 7—❑ HOLLOW STEM BORINGDEPTH M //6 JSBOLTEDTRAFFICBOX [I STOVEPIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRNEN DAOFBOREHOLE Rrl ❑MULTIPLE CASINGS❑MULTI-LPELWELLCASING CIA V,SOILVAPOR PROBE :7 ❑ MUD ROTARY CASINGTHICKNESS TYPE OF GASIN : [I STEEL [I PVC [IOTHER [ISOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING 59 Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION farsmae.Orarel D HANDAUGER GROUT SEAL DEPTH TREMIETYPETOBEUSEO []AUGERS ❑HOSE YLPIPE ❑ OTHER ❑ OTHER� GROUT SEAL PUMPED? ❑Yes'!,No (hole:Maximum Freefall Depth Is 30 FQ WEWSOILBORINGIDs Iuwy > -5 GROUT SPECIFICATIONS As 7'�Q $-/C-49ki i), r- r0Al DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: tCHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE []PIPE ❑MUSH OOM CAP ❑3 feet below surface or feet below surface if 4 feet COppMMENTS: W /f W1/1 b� rr (l AAID CrO,a/P/e/P (r(J O0 W;�A� S$-/ farIS(� W// 6� �J Comple •%=) 4*4'x I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable allfornia laws. "'� Signed one e�� . a'1 TillelCompany 7 ? P MUirf' eang >/Nr �2d�ySl1. Print Name S-F�) e-�'. , AI V DEPART EN USE ONLY tl Application Accepted By: ! o-•-- Date Issued: I q I �O Grout Inspection By/Dates: IV Destruction Inspection By/Dates: Facilit /Site Information \' FA Name L-oc,.t 'Q� •`T FA Address kwr Glr FA# �2 I PRO pS 4 3$?° FA PE WP Reviewed By 6 Work Plan Dale •'-rU�I .0 ❑C57 Er657 Autharsatlon for other to Sign Permll VWx1i0sCorrip ❑Workers CmnpWavef ❑Encroachmenl Permit ❑Access Agreement a eae Agency Approval &KFR COMMENTS/CONDITIONS: f5oltkvm sta.� Q-A- Us IC. • � PvXh�o-✓\t 4or\ Uc'p Pro Y.n.ug} t, e- iyNykpytCa�wvr.�v� tiv�•W. WP TYPE PE SC FEE INFO JAMT REMITTED1 CHECK# I RE11 / CV'`D BY DATE 1 WELL PERMIT# INVOICE# Permit �clo I CIS $152 x s ] 10 l) In"A `-- I 11G� W 1 ' ID O 3q Oi 2- 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 O&01-17 � Bee Mtllgaeon Well Pem ft Appliwpon J O � L( 7 -t 4 w-2 x � S-4, t-1 RVU L- -� t I(I 1 A ,n C ...,.,-„- 6