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i <br /> ,� <br /> SAN J 0 A Q U I N Envu r°onnnental Hee ®�@o ri' t <br /> C(.i tJ f'J ) Y f <br /> fiNV ; <br /> AIyEN/ <br /> SITE MITIGATION WELL & BORING PERMIT APPLIC�1 <br /> For Wells and Borings Used for Contaminant Investigations and Remediation �S <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 11OLIrS Advance Notice Required For All Inspections <br /> Application Is hereby mado to San Joaquin County for a permit to construct and/or 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 419L/ AGV4n 1AP., KI'A Cily/Stale0p ADI k+0 OA OQW& Phone � <br /> Cross Street �a�l rA ct S4 APN _ <br /> Property Owner* B L m'j '-q'<M0 \ '/' / Phone <br /> Address .O, 3rJbO CltylState/Zip�ni�ICq r !CS l (o bo I <br /> C•57 Contractor Y ( License# �.5 t/31)22 Phone <br /> Address _QSO I�o,i e- City/state/zIp I/Doi­"lae2, 64 �S <br /> Consultant/Sub-Contractor A>" p(r License# Phone <br /> Address w)a' L4 _ CllylStatelZlpSn�VCLrner` <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsAlVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONFrORING HOLLOW STEM BORING DEPTH 357 O BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERCRIVEN DIA.OF BOREHOLE b 11 ❑MULTIPLECASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS cln 40 TYPE OF CASING: ❑STEEL A PVG❑OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes 53 No Bo"DIa: Casing Ola Casing Depth: <br /> ❑ INJECTIONIMgavnrom I. ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO 13E USED:§4 AUGERS❑HOSE❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? tj Yes❑No (Nolo:Moilnum I'molall Depth is 30 R) l <br /> WELUSOIL 80RINGIDs GROUT SPECIFICATIONS 01V-o). 4 Wf eo {-(�1Dnd_ ClIrAi )S /+0 ]Vrr"C!(E <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:fCHF(`K ALI- THAT APPLY) <br /> #WELLS TO BE DESTROYED _ _ ❑OVER-BORE DIAMETER of Inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of__feet below surface <br /> GROUT SPECIFICATIONS __ ElEXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED AUGERS HOSE PIPE MUSHROOM CAP ❑3 feet below surface or feet below surface If>3 feet <br /> COMMENTS: <br /> l lerebYfertify that,I.Am authorized to;complete,this application and that the work.wlil be done In acpordanco w) <br /> S n J0111i County Ordinance Codes And standarde,and all other applicabwCallfornla laws.' <br /> Signed Title/Company '',// &Jr r {f !ti/)� <br /> Print Nam- <br /> �lp Date <br /> Y—/(y 217/H <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By: r`' ADate Issued: A <br /> Grout Inspection By/Dates: ___ <br /> Destruction Inspection By/Dates: — <br /> Facliit lSlto.Information p n <br /> FAName l;'e„`tCs� y!wt `�fUf72� FAAddress NL al (�/L D�JL� .Sr FA# JU"S–is PR# G(�VL: <br /> FA PE WP Reviewed By L✓ )( Work Plan Date <br /> []C-57 t2 -57Aulhorimiton forOlher to slgn Permit [JWorkers Comp ❑Wakers Comp Waiver ❑EncioachmenlPermll []Access Agreement Q Lead AgencyyAppmval GMFR <br /> COMMENTS/CONDITIONS: <br /> F`�P-P-�-ip <br /> PE sC �62 <br /> FO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> �I�r. $1KSi. 1d`1 L �' 1 z� L�('C'U„Y ►"� <br /> 1868 E. Hazelton Avenue i Stockton, Callfornia 952051 T 209 468-3420 1 F 209 464-0138 i www.sjcehd.com <br /> EHD 29-0100-01-17 Silo MIl gelion Well Penult Application <br />