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SAN J O A Q U I N Environmental Health Department . Cnt-.f NTS, 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 48 Hours Advance Notice Required For All Inspections 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 9-111/5.3,and the San Joaquin County Well Standards. Job Address Lt, C6/ /WAri City/State/Zip sj ,�7oiy(:�4 Phone Cross Street // APIN Property Owner' 1.,r,ies�d^_S . 4,CC Phone Address 39W �7p.6f //?i ,�c�1, J,,26- /-1 City/State/Zip S/=Z/.1 '4�:A 9'"/.1 C-57 Contractor 4-L4&C& - sacze�Z r License# A!E!>y a / / Phone F/G 371-/V j q Address 36-g-r-3 ,dlvrl City/State/Zip (,J. ,SgcC4 '/J-6 f/ Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIOIr1S ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor]Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ] ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air 5 are Ozone T—❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: C3 AUGERS ❑HOSE El PIPE OTHER C`' l0 r4 vr� (� OTHER:S&/. S .CROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Fl) c WELL]SOIL BORING IDs S Q f�Q„7 ( S'd/S— GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERF O ED: DESTRU TIO-N METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED ❑0 -BORE DIAMETER inches to depth of / feet WELL IDs - RESSURE GROUT To of feet below surface GROUT SPECIFICATIONS EXPLOSIVES rom �to I11_feet below su TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE MUSHROOM CAP ❑3 feet below surface or eet below surface if>3 feet COMMENTS: d&(co- A cjko4 --ork 1 her y certify that I am authorized to complete this application and that the work will be done in accordance with 5a 'Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company i Print Name LLA S,�< Date L-,-,,c Z '-ACr.t hl L- s q s s vc r,'\ 7� DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: 3N I Z Destruction Inspection By/Dates: Facility/Site Information FA Name yj „ f' FA Address /, ' ��/T t& FA# v.(��$/J PR# 6(moo FA PE 0� `' WP Reviewed By V° Work Plan Dale -57 ❑C-57 Authorization for Other to Sign Permit Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval MFR COM ENTS/CQNDITIONS: (Uu J 1�f�/ /) / � _r u" � ,/, S lam( l� LL", "� ,� - / WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit O� $152x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34261 F 209 464-0138 1 WWW.Sjcehd.com EHD 29-0108-01-17 Site Mitigation Well Permit Application