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oR°t�tN c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> e• .a <br /> W. X <br /> • — 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com <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 Dpepveel-opment Title,Chapter 9-1115.3,and the SanJoaquinCounty Well Standards. <br /> Job Address ?Z-4 LSA-1 City/State/Zip J �rJ"f hone <br /> Cross Street `V APN , l T7��w7�✓ (� <br /> Property Owner* Phone <br /> Address ni o1 Alt th City/State/Zip /r, <br /> C-57 Contractor V C f Y i l L i�L License# L k Phone <br /> Address `7 ! GIA <br /> �,'1/ i 1'hY��2 UA / Ll5� <br /> Consultant/Sub-Contractor CIA License# Ph ne <br /> Address AIM, ��n J � JU�� ��1) City/State/Zip � ✓�ZJ� � G'� �,i2(Q�t} <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsAtVells Require Access Agreements or Encroachment Permits r <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ; 1 Er HOLLOW STEM BORING DEPTH El BOLTED TRAFFIC BOX M<TOVE PIPE <br /> .EXTRACTION(Vapor/Water) y� _❑ HAMMER/DRIVEN DIA.OF BOREHOLE CSM LTIPLE CASINGS❑MULLTkEVEL WELL CASING DIA <br /> OIL VAPOR PROBE T ❑ MUD ROTARY CASING THICKNESSlid �l TYPE OF CASING: ❑STEEL M VC ❑ OTHER <br /> [ISOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING❑Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH i ;- TREMIE TYPE TO BE USED: 216GERS ❑HOSE ❑PIPE <br /> g <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? res ❑'No�(NNte:Maximum Freefall pth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [IAUGERS [IHOSE [IPIPE [IMUSHROOM CAP ❑3 feet below surface or, feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete tthisapplication and that the work will be done in accordance with <br /> K uin County Ordinance Codes and Standards,and all other aDn'llcat-la Ca ilomia law <br /> Signed Title/Company 1/IC 1 �►L' ►+'����j���' (- ` �����' <br /> Print Name Date G I <br /> A� <br /> (' DEPARTMENT USE ONLY <br /> Application Accepted By: A*7794, •4 J�!/31130 j All*�'L� Date Issued: ���dVlllcra.T <br /> Grout Inspection By/Dates: 4/s QE-G•ni w <br /> � VE7T <br /> Destruction Inspection By/Dates: <br /> Fa ill Site Information I� <br /> FA Name FA Address FA# SA <br /> FA PE WP Reviewed By Work Plan Date ENVI <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access AgreementyfA�rby R <br /> COMMENTS/CONDITIONS: q y.� "Ly¢.G[_ .o,� /'lp- ••lL �o �. ls'� <br /> ' : Civ-I - Y�:r L w-3 - YS�= E'hi-a - YOy� Ani Lr - L�p� <br /> C—xV_I- Zot2 r - Cw-3 <br /> SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan //Z/7 1,1,30 730 — qa/D ►-/3 q/23 fis U7,- t <br /> Permit $130 x <br /> Z- <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />