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LAS� SAN ,,J 0 A Q U I N �P Environmental Health Department Jr.lT ree5 15� (6� 'r y�lo `�l�.vv SITE MITIGATION WELL 8r. BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 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. q Job Address 1'7q Dt�. Mo rk tv� U t�w � h4 3�. 3`'� City/State2lp S�bL�VO ( l �'-"Z�Phone Lill)`1bU Cross Street CcU l i q 5-t'rcyt� APN I PropertyOwner* YI _P_ l l p„�„1 Phone �S �� YJSYjs Address ? `� �� Ct- ��,�cltyistaterclp rlSl /_ C-57 Contractor in �pMlirj-1 irort-4 l 5Qc1G.-feS� � cense# 6q9Phone Address 3 ul I Tw I VlI�GcyA S [4. C�ity/state2ip �^�5�� PZ (/ Consultant/Sub-Contractor .✓�.✓ j ngl&'xe .t/lc'� 1, x, P.it�i LiCal Phone (a/y) .410"(obi Address 101 �.�(�.,S(aJ'} (� City/State/Zip W4a-kA , CA 9,4(,L)6 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE J,5�� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASINO DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC (3 OTHER SOIL BORING t PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Swan.oiom ❑ HAND A4 ER ,+•_ tGROUT SEAL DEPTH TREME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER OTHER if i�1r I .�y��, OUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freetall Depth is 30 Ft) WELL/SOIL BORING IDs r 3Y Z; GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED6 i am poyzL11 S ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ( ,Ij�', �j 3 t y, r ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIPICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED AUGERS ❑HOSE PIPE ❑MUSHROOM CAP 0 3 feet below surface orfeet below surface 9>3 feet COMMENTS:DC' -�v�c1� SiX 0� SAef Otn�t Ljo i1 5 "� �JU� tD95, C7� gY �jWG.-�Qy✓i vJY�tc��ve.�1' t5 54.411ow z/'/�v r k1/.� cUl�t'C,�lotn a� Sa tl f rawYvrtw�,`'�+X k 1 i s 4w� I I - I hereby certify that I am authorbted to complete this application and that the work will be dond in accordanc&with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed + Title/Company j'a 411A 4W �^Q 111 eg'y I VISE Q S/.t GVL�P. Print Name Ij,� M amp Date 1 12:5/1 DE.ARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facill /Site Information FA Address y>' (Jr. � FA Name (1 .. S s 6 FAS l +✓� Z `� Z-Z PRO t '- FA PE WP Reviewed By4- []C-57 _ X Work Phan Date ❑C-57 ❑6-57 Authorization for Other to Sign Permit 13tidarkers Camp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agredr@nt ❑Load Agoicyl Approval [ MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO JAMT REmirrEDI CHECK#I RECV'D BY I DATE WELL PERMIT# I INVOICE# Permit y.=1.,y, j $152 x i '� � J �i 1c- iC k� tA/F'Q0 3'1 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 24-01 08.01.17 Site Mitigation Wel Permit Application v.IP XIAJ-1 isz.)k sFc>vj8iZe