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SAN JOAQUIN COUNTY tvif ® <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> •'!`� /• 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENpER�MENTgf H <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s'cehd.com MR/SERVic SLrH <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remedlation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a pem It to construct and/or Install the work described. <br /> This application Is made In compliance WithSanJoaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 8o9s /y %� o [)�rm[n /C rY , Cily/Btala2lp S'fot,k funr CA 962/9 Phona N$2-/000 <br /> Cross Street Wa 3-/ /a Met, APN 0(,(,05'()S-2. <br /> Property Owner* H w Phone3/0 3 - <br /> Address 7-5-.27O V,,>_ TCI. —City/State/zip P/c Vn� ides C-4 %Z :7y <br /> C-57 Contractor .on4ra I A"wa le, Tt,, License# G 9S 2 9'O Phone 683/ -6Z-8/7$ <br /> Address 301/ 7,,,. AlLD "rte CllylStatelZip/_a Zia; C 4 95-0 03 <br /> Consultant/Sub-Contractor fF-5E...ronI men�v l Inc. License# Phone 9/S -le 0 <br /> Address '7,L657 I&Cla oo a dVyL4 Ste- it Zea Cltylstate/Zip N & T 9H9YS <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELU13ORING NUMBER.aa INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 19 MONITORING �19 HOLLOW STEM BORING DEPTH U-2s' r M BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMENDRIVEN DIA.OF BOREHOLE $" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS -;," TYPE OF CASING: ❑STEEL❑PVC 19 OTHER P,::r-A AZC- <br /> ❑ SOIL BORING [I PUSH POINT(GPI CPT) CONDUCTOR CASING [I Y03 Et No Bann Dia: Casing Me: Casing Depth: <br /> [ INJECTION W,Souos.0,,I ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: [3 AUGERS El HOSE [I PIPE <br /> [3 OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes 91No (Nob:Maslmum Fiestas Depth Is 30 Fl) <br /> WEWSOIL BORING IDs GROUT SPECIFICATIONS J FPn /t p r In Annr/ E a <br /> SPECIFICATIONS, <br /> i <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED C]OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSUREGROUT Todeplhof feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS HOSE❑PIPE ❑MUSHROOM CAP 3 feet below surface or feet below surface if o3 feel <br /> COMMENTS: <br /> hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Cod and Standards,and all other applicable California laws. <br /> Signed �`+s Title/Company 5tnar sj.W F r <br /> /7_ �F.S Fnwvnmv.,fe/ rn�, <br /> Print Name I^CX-vl. lir Date <br /> EPARTMENT USE ONLY <br /> Application Accepted By: / Date Issued: 'Zt� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dales: <br /> Facilit /Site Information <br /> FA Name Ggt FA Address OCC- r-D FAN 00 Zi/I <br /> FA PEO WP Reviewed By Work Plan Dale jl-Zy-Js I l_ <br /> [3657 57 AuBrodnaonM Oaarto Sign Permit kers Camp ❑wonees Camp waiver Encmacnnenl Permit ❑Access Agreement sariAgemyApproval2fAFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# '.. <br /> Permit i j 139 x �' 6 IS. p• — 6 'LO 00 -777 <br /> f 41 .7 0111� 60 772,, 4 <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />