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r • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 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 Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made 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 Welt Standards. <br /> Job Address L,{ <br /> cttyistatol n CA R S'32O Phone <br /> Cross Street 1 rxy}on Z<� �tay4 PIN <br /> 3DS 2. SO I <br /> Property owner* �"`-�-- <br /> Address ^.l t Phone <br /> -Z-S-1 <br /> q-L77 -3Z7to <br /> C-57 Contractor City/state/z)p p IJr <br /> Address 2 0 License# <br /> E. {nr„ c Phone 2�.f / ? <br /> � ��� <br /> ConsultanVSub-Contractor {1City/State/Zip, f t�mr)(C'✓yJ A q�?0(r, <br /> Fnvw.\ /�®,{Q c (" 1�. 1- License# <br /> Address oto c� �,._. d� 4 ! « cityrstaterzi �lA Phone ?49-26t- 1-7 <br /> P � "if ct^X92— {---4Z - <br /> CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM <br /> EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN BORING DEPTH —IbO F} ❑BOLTED TRAFFIC BOX <br /> ❑ SOIL VAPOR PROBE DIA.OF BOREHOLE STOVE PIPE <br /> ❑ MUD ROTARY r— ^--–�__❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL BORI NG CASING THICKNESS If'xh ct O CV( TYPE OF CASING: ❑STEEL A PVC ❑OTHER <br /> ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes Na <br /> ❑ INJECTION rAr sna as omnet ❑ HAND AUGER GROUTSEAL DEPTH n_ Boring W: N-- ---C�ng�., to A Casing Depth:'.-JA <br /> ❑ OTHER ❑ OTHER: S { TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE O PIPE <br /> WELU SOIL BORING IDs (Y�1 1_��fl GROUT SEAL PUMPED? ®Yes ❑No (Note. imus Freetall Depth is 30 FI) <br /> GROUT SPECIFICATIONS re.M F­ <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> WELLS TO BE DESTROYED DESTRUCTION METHOD: H CK ALL THAT APPLY, <br /> WELL IDs A ❑OVERBORE DIAMETER of inches to depth Of_feet <br /> GROUT SPECIFICATIONS ❑PRESSURE GROUT To depth of feet below surface <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑EXPLOSIVES From to feet below surface <br /> COMMENTS: ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if i3 feel <br /> I hereby certify that 1 am authorized to compieto this application and that the work will be done in accordance with <br /> San.Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed <br /> Title/Company I <br /> Print Name <br /> _DEPARTMENT USE ONLY <br /> Application Accepted By: <br /> Grout Inspection By/Dates. Date Issued- <br /> Destruction Inspection By/Dates: <br /> Fact itV(Site Information <br /> FA Nameel� FA Address gU( �. 91& FA# <br /> 620 <br /> PR# 0 <br /> FA PE WP Reviewed By <br /> Work Plan Date <br /> ElC-57 ❑C-57 AuMor zatan for 011ier to Sign Permit ❑Wo kers Com J"11-1 3 ("1 <br /> COMMENTS/CONDITIONS: p ❑Workers Comp Waiver ❑Encroachment Permit <br /> ❑Access Agreement C3 Lead Agency Approval ❑MFR <br /> SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY <br /> DATE SERVICE REQUEST# fNVOICE# <br /> Permit ,;)il,�/ '31 , $139 x <br /> inJP 2,-W3 S2­3 <br /> EHD 29-01 10-26-2015 <br /> Site Mitigation Well Permit Application <br />