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• • MEIV ,j Pau1a.• SAN JOAQUIN COUNTY / u 2lfl/ u. r ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENT AL HEALTH 1868 Hazelton Avenue, Stockton, CA 95205-6232 PERMIT/SERVICES Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com IFO 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 its made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 16095 ISS, U/onco /`,Ct.J City/State2ip ✓rGL K+'On C4 95Zl / Phone 2,09 qTZ- /oma Cross Street Was -Ip A,, IC- 9 d. APN C)66003 Property Owner' //Owa r vainberci Phone Vo 363-?-7757 Address ZSSO •� e- vl /� Z3 City/State/Zip P/os Var4eSCA, 90ZZy C-57 Contractor 6re-1 Dn'llin!n B IB5-&j Ti c- License# Phone 07-5) 313- T90 Address 9'5O- Dawe. ,Qd. City/State/Zip�r-/� C41 94553 Consultant/Sub-Contractor PGS lcrl TnC. License# Phone (q4 Tp?—1 00 Address 7(065- Re4,oc d 13/✓4. S r'fe lay citylstatelzip Nn rainy CA 9Y95'5- CONSTRUCTION Y95'SCONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ^-'Zol ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vaporfwater) 0 HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER $1 SOIL BORING —'_❑ PUSH POINT(GPI CPT) CONDUCTOR CASING [3 Yes ❑No Bonng Dia: Casing Dia:Casing Depth: ❑ INJECTION IAr Soama.0zanel ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? []Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WEW SOIL BORING Its GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs El PRESSURE GROUT To depth of_feel below surface GROUT SPECIFICATIONS [3 EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑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 �y� San Joaquin County Ordinance Codes and Standards,and all other applicable rCaalifornia laws. 11 T Signed /{,( �+ (� /., Title/Company Senior SlafT Print Name (Tg V r n �-^:P O Date 3Z 3 1 ! i DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: F III /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Dale ❑C57 ❑C57 Authorization for Other to Sign Permit ❑Worker Comp ❑Workers Camp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Appmval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO JAMT REMITTED I CHECK#I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# Permit $139 X EHD 29-01 10-26-2015 Site Mitigation Well Permit Application