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SAN JOAQUIN COUNTY y ENVIRONMENTAL HEALTH DEPARTMENT N• [ • •j 1868 Hazelton Avenue, Stockton, CA 95205-6232 .. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web.www_Sicehd.COm <_IF__o__0 SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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. Job Address Z1801 �. Nr' p0 City/State/zip E`��Ir„n CA Q5�2C,Phone ZUq _77Z Cross Street ��„� All, K) �n tIYC c10 Property Owner' _QO t�� f falrf LiA ,r Phone Z dq-2 72�-SZ76„ Address 2lRUk (;. E11it�nw+y-� ,`L(7 City/StatelZip EtZCe j0V\ (A C-57 Contractor �u.4ese}t_ j� \+t y,,,� L„p License# Phone 530-66 2-Z�SZ� Address 2.0%Cp I_. AI,n not. t City/State/Zipl_h)�l4nr).LA Consultant/Sub-Contractor xtrnn�elN1^t "4LS Con'.ult,�n�,License# "A Phone Address �,ZLU Lt �c.v.itr.n o1I SV� ` ri City/State/Zip `rytlne . CA 9?fsbZ CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 MONITORING Z fX HOLLOW STEM BORING DEPTH too r'+ ❑BOLTED TRAFFIC BOX STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ;nC l' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS "c(U TYPE OF CASING: ❑STEEL J8 PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes KNo BorMg Dia NA Casrq Dia A L Casirg Depth: N P, ❑ INJECTION(Arswm.owmi [IHAND AUGER GROUT SEAL DEPTH ^(oS F F TREMIE TYPE TO BE USED: p AUGERS ❑HOSE fig PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs mw-p l rAL0-PZ GROUT SPECIFICATIONS C<-w� DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK.ALL THAT APPLY) #WELLS TO BE DESTROYED t.JA ❑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 Cl MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 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 Cali mia laws. Signed s Title/Company t^x�o((„ �,L K�n�t}„�? {LS (onsuY►-4s Print Name Ot-ze-j l o' NOV1c. Date Mrtrf In `� i . Z LD I`1 DEPARTMENT USE ONLY Application Accepted By: - _ Date Issued: i4 -1 1 Grout Inspection By/Dates: i Destruction Inspection By/Dates Facili /Site Information FA Name FA#v•✓/�j Ir'' L<.:r/�ey CavttC FA Address 9 t f%w 1 PR# FA PE cw";' WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Peril ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit $139x - , v ,3k•r- i -'I,tI I- - (li-oc) I ` n 09`i y)r11l1 slI:0o•?77.0, EHD 29-01 10-26-2015 Site Mitigation Well Permit Application