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iopQUtN a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 c4�IFOR�`P 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 is�m7ade in compliance with San Joaquin County Dpeev-eelloopment Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. '24 Job Address � L S. a[/l () Wt City/State/Zip l hone qY,, , y - CrossStreet ,VV APN ��(�wzJ ,'r '"tiJ 0 041 Property Owner* ii P}ho7ne (f"G/��` 3 Address /1 d►A�Q 1 City/State/Zip 1 (4 P,61, (A/ ((,4( / t� C-57 Contractor V C i 11 i� License# (- CY / Phone Z5--3!3-5-&D Address /� City/State/Zip Orl i l't�Y�0L CA Consultant/Sub-Contractor LA License# Ph ne Address-W,4' Wo City/StatelZip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits Yy TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING �_ HOLLOW STEM BORING DEPTH U ❑BOLTED TRAFFIC BOX BIiOVE PIPE El EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Sc Li L-( C HYPE OF CASING: ❑STEEL B*PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes Epo Boring Dia: Casing Dia: Casing Depth: El INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH �/qc, ak- TREMIE TYPE TO BE USED: GERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [3 Yes ❑NoN,onte:�aximum 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: t e b certify that 1 a i a plication and that the work will be done in accokd ';`ce r' � . J PTU-)_0. a anc `tidards and all oth8�aonr;GaFre CaliiorJii Signed Title/CompanyVIC 1 �G�hj ( v Print Name Date a l DEPARTMENT USE ONLY aa Application Accepted By: T/FL+ / iL i b'.� Date Issued: (/i2 3//.5— Grout Inspection By/Dates: &A V"-r Destruction Inspection By/Dates: - "�1• � C® Facilit /Site Information 00"2 3 FA Name FA Address FA# 10414.10 FA PE WP Reviewed By Work Plan Date E co Y ❑C-57 ElC-57Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit El Access Agreement ❑Lead Age pp�il TAl COMMENT�S�//CONDITIONS: �S'ct� - . v SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Y 7 f I So N-"9L6 Permit $130 x EHD 29-01 6-23-2015 Site Mitigation Well Permit Application