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I <br /> SHAUN Environmental Health Department <br /> 11 <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 applicatitiion is made in Compliance, <br /> With San Joaquin County Development Title.Chapter 9-111115.3,and the San Joaquin County Well Standards. .f <br /> Job Address ��It» jl.)L.ltln, T'dLL�'If VI, RU�i� CItY�tatceclZ(l�P Lk'F'InJ`Ufl CA,IJ Phone (,Sdc� �ll�'-1� 1 <br /> Cross Street / YL 'G- APIN L> d <br /> Property Owner' Phone BU`I -`126: <br /> c tonsiopRtrL�L,OA& IVA 230D <br /> Address �(7llry N'I Dy�y p.e-L..'f�yP.n r12 � <br /> Cal Contractor Cr�vtw Vhw�ev.�-0.l �nv6tw' h�5/X.1�1,�'eh Licenself Phons � 1 <br /> Address V I V P� ,p p,CilyfSSttate2lP A Of'O s C.A, 93'003 „ ,/y <br /> ConsultantlSub-Contractor V^Wt4l Ea ✓I rYA��Ltc"eh1Se# — Phone (SID)gla:iLaA <br /> Address JUIN-ZZI.A Ave �5f4r+-oof t cityiscaterzlp ( aUp-n 6 A 1q&0& <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BodngsMells Require Access Agreements or Encoachment Permits <br /> TYPE OF WELLSORING NLRASER INSTALLATION TYPE CONSTRUCTION SPECFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BIXtING OEPrH J ri r ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> O EXTRACTION(VaWW9.) ❑ HAABAERIDRNEN DIA.OF BOREHOLE 7 5'14 O MLO TPLE CASINGS❑MULTH.EVEL WELL CASING DIA <br /> C1 SOL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC❑OTHER <br /> A.SOIL BORING ❑ PUSH POINT IGP/CPT) CONDUCTORCASING OYes 0 N Boring Die: Caen 012: Ces"One <br /> ❑ INJECTION W&n,oimah ❑ FiANO AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: O AUGERS O HOSE O PIPE <br /> O OTHER {7Y OTHER: GROUT SEAL PUMPED? O Ye, ❑No (Note:Maximum Freehn Depth is 30 FQ <br /> WELLIWIL BORING IDOL ppL&fSr ' l OIr SPECIFICATIONS <br /> I f r 134r S.Qiln <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED (o {Y.eA.n�I�db.Y'YJ W e, S ❑OVER-BORE DIAMETER of_inch"to depth of_feet <br /> WELL IDs BI 8 L 8 3-�Lr F ❑PRESSURE GROUT To depth of (eet below surface <br /> GROUT SPECIFICATIONS "P.c-r PM t [I EXPLOSIVES From_to—feet below surface <br /> TREMIE TYPE TO BE USEDAUGERS HOSEIPE MUSHROOM CAP surface a 3 feet below surfafeet below surface d>3 feet <br /> COMMENTS:Peohy-4 c 4-ot� f of <br /> 42L'i^�VID✓ 100 ei V,15> 1-0 <br /> 1 hereby CWM that I am bullionzed to complete this dilliplicadw and that the wom wall be done In aeeordanu with <br /> I San Joaquin County OMlnanu Codes and SWMards,and NI otherapplicableCaalikim a taws. <br /> not <br /> Signed Titkrn <br /> /Copany c -IZ' S-eiew11:+1 Pk i- hey- <br /> Poynt Name +t-,4AA /�L(�.d�U OIC Date lolrh I r� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: •7'"""1 Date Issued: <br /> Grout Inspection By/Dates: <br /> r <br /> DestnKXion Inspector By/Dates: <br /> Information <br /> FA NameY „-CU.,-Iiik FAAdMess 1�i1?i: Yl.,.i .ten l' fq# �L" ��Z3 i, <br /> FA PE '1 Li S"C' WP Reviewed By ! x Work Plan Date i,L0 It-7 <br /> OCG57 FC 7ftohr'rndmformwrmsignpemA eescarp ❑Warr✓aconewalver ❑EncroYAmptPomin OAmen AQeeroM OLMd ApMyAXMM e6i <br /> COMMENTSICONDITIONS: <br /> lwprmEl PE I SC I FEE INFO JAMT REMITTED CHECKM I RECWO BY DATE WELL PERMIT# INVOICE/ <br /> Permit �lni� 3 i �[ill52x � -'6�'�i L�C��O`♦ <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> END 2941 OWl-n ae sMNpsson wed PamT APPdradan <br /> QIP -:)AIu3 sz} 11sLn3 1 LlS�6 oobho � L j( IoI 1� SR-ooiY y- <br />