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I • SAN JOAQUIN COUNTY . �rN• . O�k , _` er ENVIRONMENTAL HEALTH DEPARTMENT V/V/RAWI,,, q� a RMIT/SERVi ESLrH 1868 Hazelton Avenue, Stockton, CA 95205-6232 C r Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'cehd.com cid•r'a 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 UPS- N. /lip B/nco Rd• CltylStateop S>;oc.kk, 95-2/9 Phone Zd9 75Z'1000 v Cross Street Wos1` $ /yl,/t 2d . APN 0166 0$030 Property Owner' r Phone (3/096.3- 75- Address 2550 (..k— / City/State/Zip p Verd /oz e sy L4, Lo Z-?I/ C-57Contractor Fr;,,,,,,,c„ /nl ( ..n k.. / //Scnc,'o f5,Z+.License# 6959-7o Phone Address 301/ 7—, ,'n )91,11's p 01,le- CltyiState/Zip fes "A q$bo3 Consultant/Sub-Contractor / C5 Fwaan..r e.r�zr/ z'.,, . License# Phone y/6 Address x(65- Qpdwomd ntid, $,. '/c 200 CllylState/Zip Nov.% rr41 fy91V5- CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite SoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �.MONITORINGS HOLLOWSTEM BORING DEPTH 2O 25'bct ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERORIVEN DLA.OF BOREHOLE it"_0 CASINGS[I MULTI-LEVELWELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 2.11 TYPE OF CASING: ❑STEEL ❑PVC BI OTHER &Ak ❑ SOILBORING [I PUSH POINT(GRI CPT) CONDUCTOR CASING [3 Yes fZNo Bodre DW: Casing Dia: ng Depth: pth: ❑ INJECTION IArawoe Opens l ❑ HANDAUGER GROUT SEAL DEPTH TREME TYPE TO BE USED. ❑AUGERS [I HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes 0 No (Note:Maximum Freefall Depth Is 30 FI) ,At WEW SOIL BORING IDs GROUT SPECIFICATIONS 21 ke '!u le AAorc 5» A k iss l �C aM.re �hcn b�•}e w,•/I A• ,t-e...,'r I ru/exdi em en I ANF DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) J #WELLS TO BE DESTROYED ❑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 El HOSE [I PIPE MUSHROOM CAP 0 3 feet below surface or feet belov 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 California laws. Signed C,/c9-,�-•--�-- Title/Company,�p,,,' Print Name Q V,n Cr 1S Date 6 ; / DEPARTMENT USE ONLY • Application Accepted By: �1-- Dale Issued:��/ /7 Grout Inspection By/Dates• Destruction Inspection By/Dates: FA Name Y _% �� FA Address fA# •stn�� PI2# Or/' FA PE Z_G� 6 L7 WP Reviewed By Work Plan Date /(,_ _ /3— /}. _.� G51 0C-51ANhodullonforOlherto Sign Permit workers Camp ❑womwrscomp Weiver 1pemit ❑Acmes Agreement lead ApnryApprwal FR COM MENTSICONDITIONS: SR TYPE I PE SC I FEE INFO JAMT RENfTTEDj CHECK#I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# Permit 139 x 61/ 6 b 77j( EHD 29.01 10.26-2015 Site Mitigation Well Permit Application