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oA `'IN SAN JOAQUIN COUNTY <br />RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT AUG 17 2015 <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />• �q•.. - �;:� . Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.s' ov. RBNME�T� HCH <br />MIT/SERVICES <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 9 36 w cm, f' y s{- . city/State/ZiiP m aVl �q-0-, oq I53 Phone(ffUG�3 59-d70 <br />Cross Street kd 0.II'( S) I { &- APN � � �• � Ga I ` (J f� (i /// [� <br />Property Owner* �/ Y 1 Z tj Cly �'1 C • Phonej t0 � �' S y �cs <br />Address a� 1. <br />toGC.c�rst ��' city/state/zipppjr?��. C�Y-1• qI TU fv t -t`4 T-� <br />Contractor p TY? G• i s n p i C, c-51 License# (4 �3 Phone(800) 3� _a T <br />Address PG hX Ell(0 1 city/State/zip IV IKM C,C4 9.3!9'4!V �7 r <br />Consultant/Sub-Contractorc5►r 1�t rG�-- ,, c� � License# 7 �; s q .5 Phone L�_ li� ' �U <br />Address 347-5 w , Sh Q (u & Q• �\104 city/State/zip GirC 17 G .j C! q 3 -•- i I <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/ Vells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLMORING <br />❑ MONITORING <br />❑ EXTRACTION (VaporMater) <br />❑ SOIL VAPOR PROBE <br />Gf SOIL BORING <br />❑ INJECTION (Air Some. Ozone) <br />❑ OTHER _ <br />WELL/ SOIL 80RING IDs <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ HOLLOW STEM BORING DEPTH {0' ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />❑ HAMMERIDRIVEN DIA. OF BOREHOLE— [1MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />3 ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />90'HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER GROUT SEAL PUMPED? ❑ Yes ❑ No (Note. Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS 1-4,e e"'t Cts` CY J <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance codes and standards, anti anower appJucame)canrornia taws. <br />Pr <br />Signed ,aTitle/Company Y ( i U +- 1 P -bri lr/• — <br />Print Name %4 �( j�jk GY{j DatMi� { Gl <br />/ /% DEPARTMENT USE ONLY <br />Application Accepted By: %/ ,�"Jy'e'L 13y% Date Issued: �Jr <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facilitv/Site Information <br />FA Name FA Address I <br />I FA# <br />I I PRN <br />FA PE WP Reviewed By <br />I Work Pian Date <br />❑ CS7 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp <br />❑ Worker's Comp Waiver <br />❑ Encroachment Permit <br />❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMM ENTS/CONDITIONS: <br />SR TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED CHECK# <br />REC,VBY <br />DATE <br />SERVICE REQUEST# <br />IVOICE# <br />N <br />Work Plan <br />Z')4� 3 <br />5'13 <br />_� 'C <br />c' <br />'DD <br />i f✓ <br />11 <br />t <br />�' 4, <br />Permit <br />Z% <br />3) <br />$130 X`7'G <br />g�af?.115 <br />c 19 <br />h5 <br />✓ k C /?-g c? 5 <br />oxo j* 0-7010$ rte' <br />EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />