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� SAN JOAQUIN COUNTY zi r `r ENVIRONMENTAL HEALTH DEPARTMENT :� ,� '• 1866 Hazelton Avenue, Stockton, CA 952056232 Telephone:(209)4683420 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 Appication is hereby made to San Joaquin County for a permit to mnsbirt and/or instal the work described. This application is made In compliance with Sen Joaquin County Development Title,Chapter 9.1115.3,and the San Joaquin County Well Standards. Job Address 1819 South Argonaut Street CkpStaftOp Stocl*^CA 95206 Phone C4orts Corsa Street Irene-- APN -- Property Owner* John Taylor Fed1lq r do Eric Jenks Phone 510-23"282 Address P.O.Box 511 Citotats/Zlp Yuba City,CA 99991 C-57 Contractor Directed Tech Ise Llcensa>R 720357 Phone 800-239.6860 Bele(onta,Pennsylvania --- Address 1110 Rolk Rides Dries Cit0tata/2Sp 16823 ConsuldntlSub-Contractor Gwsyn*c Consultants Inc. --- --1-kenseE - - ---- - Phone 916 637 8018 --- Address 3043 Gold Canal Dr.Suite 100 CKVIIStateMp Rancho Cordova,CA 95670 C-) CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BonrK;&Wells Require Access Agreements or Encroachment Perrits m_ TYPE OF KI-1.0 RING WHOR NSTALLATION TYPE CONSTRUCTION SPECIFICATIONS M ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 2025 R bga 0 BOLTED TRAFFIC BOX ❑Sl OVE Pa'E O ❑ EXTRACTION(VaparNYatr) ❑ HAIM )RIVEN DAA-OF DOW-HOLE 6 itd— ❑Ill TTPLE CA3NGS❑WATkEVEL WELL CASING DN [I SOL VAPOR PROBE ---- -0 MIA ROTARY CASNG THICKNESS TYPE OF CAsw- ❑STEEL PVC ®OTHER HDPE C [I SOIL BORING T ❑ PUSH POM(GPI C� CONDUCTOR CASING ❑Yes 0 Me Bong D¢ _camp Do: Caig Dwk ® INJECTION(Ar,%mm mnel 2 ❑ HAM AUGER GROUT SEK DEPTH 1511 b9S TREME TYPE TO BE US®'. ❑AUGERS ❑HOSE 0 PIPE ❑ OTHER ❑ OTTER GROUT SEX W MPH)? ®Ya ❑NO (ND&:Mmrn F,--W DapM a 30 FQ ~ For racer DI nnriteed ~' WElU SOIL BORIIG IDs HMV-AB reBetrhle D'A GROUT SPECIFICATIONS Grout mi%m b SJCEHO and termed dawn.N*-_-- r� 0 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHECK ALL TKAIT APPLY) If WELLS TO BE DESTROYED ❑O'VERR41ORE DIAMETER of indnee to depth of feet WELL Us ❑PRESSURE GROUT To degh 01feel bebN Suxface GROUT SPECIFICATIONS_ -------- --- - ---_----_❑EXPLOSIVES From to 15W below surface TREME TYPE TO BE USED ❑AUGERS ❑HOSE ❑PPE ❑MUSHROOM CAP ❑3 feet below satave or feet below sxface if>3 fed COMIWNTS: -- -- ----- - I hereby uxRlfy that 1■m authorized to complete this application and thatthe work wO be done in accordance wlth San,iloaqu / ourRy7 Ordinance Codes and Standards,and all after applicable Calfl mis laws, Signed _Trt>ejcompamr Pmiri Name • ',?'/?MPS /"1 �/.'t S 1'i Ube-__--. Date tiT'tJ�r' / LeJ/7 DEPARTMENT USE ONLY Appication Acoepled By:—--- ------_ - - - _--- Date Issued: Grout Inspection By/Dates: Destruction Inspection BylDates 7 FA Name I FA Addmas I _ FAIT PRt FAPE WP Reviewed By i Wnlr Pfau Date 1 ❑G-17 ❑C-17 Aut s zmw br ONw b Sign PamA ❑WMWs Carp ❑Wwje e6 Camp Wa vw ❑blaoedvosrl Pemit ❑Ames Agmenunt ❑Lord Aywwy Appewl ❑I FR� COWEKTSICONDITION5 8P E PEE- SC 1�FEE NFO —AMT REMDTTEDDCHECKi RECV9 BY DATE VICE SERVICE REQUESTS AYV010ES EHD 29.01 08-01-16 Site Mitigation Welt Permit Application