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0 SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 �4 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com 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 isl4made incompliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 2-gZ( �t0.\), '?,oaA City/State2ip 1lxla1flrl ,C A Cli Phone Cross Street Q KEG �- - 9-41 • APN OL"( Property Owner O•i+r Orc- 9-\Vf,0Z I YVk- Phone 2tpq- 110-113`+ Address Io107�_—"f1ln irk CJt-• City/State2lp1Werh- � \'L- 'e-*' Ol S3lo� C-57 Contractor Woackr�a-i-A License# CS,-.!J7- 11C01Phone 1LTI' 5-11+4300AddressraCS ¢aver I City/State2ip 1�-Lo veAo-7 C--R CILASIl Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Bodngs/Welis Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER [ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS , '071MONITORING �_PJHOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PPE ❑ EXTRACTION(Vapor Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE r ❑MULTIPLE CASINGS❑MULTILEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOFCASNG: ❑STEEL L(PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yea ❑W Boring Die: Casing Dia: Casing Depth: ❑ INJECTION(Aa Soaoe.arena) ❑ HANDAUGER GROUT SEAL DEPTH TREME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PPE ❑ OTHER ❑ OTFER: GROUT SEAL PUMPED? bi7es ❑No (Note:Maximum Fr j(1 Deph H 30 Ft) ` � 1 �. /�� WELL'SOIL BORING ps rA W'S Ili GROUT SPECIFICATIONS 20-"A. 4-r 'T.LD ___ -13.P rn 3 LS key CWL P -4-1- J'ra!�..�--- wp l� C2ME-Vva- DESTRUCTION WORK TO BE PERFORMED: DE RUCTION METHOD:(CHECKL THAT APPLY #WELLS TO BE DESTROYED Ij VER-BORE DIAMETER of—I_inches to depth of 3 D feet WaLIDS (AIA/-S []PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS YVQ Q.1n': yrf• I.) Z C rmrXtAl EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below sun . .. ' cI 1——` COMMENTS:�1��-�\ _ 5/1"\OC �3 J U 6 Cc�exe l� odes ` Ll x 49/ X Lk D 1 I hereby ce ify that I am authorized to complete this application and that the work will be 11 `Irl San Joaquin County Ordinance Codes and Standards,and all other I L IIII9IIS — 30 Signed .VLl1/�n��aF�7?J, Title/Company (� _ Print Name CO u'na 1jco j WA✓cl. Date DEPARTMENT USE ONLY Application Accepted By: �( , � ✓ Date Issued: O� Grout Inspection By/Dates: L&A S�0073g Destruction Inspection By/Dates: Facili /Site Information FA Name /l- W 7A1 TAroj, I FA IFA# I 0C t PR# 10Sz 80 FA PE WP Reviewed By I 1AQ lWorkPlanDate W57 ❑CZ7 Authoriufion for Other to So Permit ❑Worker's Cornp ❑Worker's Comp Waiver ❑Frxmachment Permit ❑Access Agreement fa,lead Agency Approval ❑MFR OMMENTS/CONDITIONS: tt\ Yv%t.V-, ntwai�.lr•t d�coi'wY{p.Q y Q'L)P�p��(.I V1t,] WI•�'[•t t00%G1dt (n)c f C MW-SR Y^co -[ F.c tn7^ $nau -S cnotM SR TYPE PE SC FEE INFO JAMT REMITTIED1 CHECK#I RECV•D BY I DATE j SERVICE REQUEST# INVOICE# �0 Work Plan ZA 03 390 30(x. &t711 ( mteNs -+-SS-30$O Permit IctoI $130x I: I30 00C. 5M 4i 1!5r TS 6 ;,aoZ EHD 29-016-23-2015 Site Mitigation Well Permit Application