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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 'P Telephone:(209)468-3420 Fax:(209)468-3433 Web:vvwwsicehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Barings 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 �4-q`i" W a V e-i"C .y �15 a City/State/zip L- I NJ ck e,,J;��_Phone Cross Street C. r { u,v IZ o cb 3 7 H Ivy'J 2-t APN 09 s 0 0--z I, Property Owner" v C PC l �°1 a Phone 0 "9— of —3o 66 Address .C I O FF H x Z e C D I J A v�L-- City/State/Zip C _ X-ontractor 4 I t r f C- License# ) -L Phone Address 4- cls k, e City/State/Zlp 9:00mr_L A r Consultant/Sub-Contractor Li e# '7UJ76 t; Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsMelis Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5;e -ra]ia I[.— BOLTED TRAFFIC BOX ❑STOVE PIPE IIEXTRACTION(Vapo NVater) ❑ HAMMER1DRIVEN DIA.OF BOREHOLE ,16 it ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA El SOIL VAPOR PROBE ® MUD ROTARY CASING THIGWESS 01 a TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(&Soame.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: ✓ GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs 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 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑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: � rp I`+ W C--C.,..61 C -1!1 1 ni i'�-@ Vv C�d 4 e rv\0. s S ( f'('%a 501j. . I hereby cfar*that']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. SignedTitle/Company C j3 i— I Print Name t a Date S/ '�U) {� DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address IFA# I PR# FA PE WP Reviewed By I Work Plan Date ❑C-57 ❑C.57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit $130 x EHD 29-01 6-23-2015 Site Mitigation Well Permit Application