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M SAN .JOAQUIN COUNTY c �a r ENVIRONMENTAL HEALTH DEPARTMENT M 1868 Hazelton Avenue, Stockton, CA 95205-6232 y cNoLFH Telephone:(209)468-3420 Fax: (209)468.3433 Web:www.sicehd.com = o SITE MITIGATION WELL & BORING PERMIT APPLICATION r" 1+ D For Welts and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaqun County for a Pannit to const uct andlor instal the work described. This aMcabon is made in corttpfance with Sen Joaquin County Devebpmert Title,Chapter 9.1115.3,and the Sen Joaquin County Weil Standards. Job Address 1619 South Artonaut Stssat Cky/StalaMp StockM4%CA 95206 Phone Norrs Cross Street Irene -- - -- APN Property Ownee John Taylor Ferthlizer do Eric Jenits Phone 510-236-62E2 _ Address P.O.Box 511 CitIntater7Jp Yuba City,CA 99991 C-67 Con ractew Directed Techno --les -- License* 720357 Phone 600-239-6950 - ---- ---- --- -- -- es - -- --- 8elkforrte,Parytvarria- Address 100 RolYnp RidOa Drive CW' kava 16123 ----- �D— 3 ---- ConwNarMlSrb-CartradorGeosyagc ConsuilAnts Ina- Licertud Phone 916 637 5IMS Address 3013 Gold Canal Dr.Suite 100 CltylStab/Dp Rancho,Cordova,CA 45670 CONSTRUCTION WORK TO BE PERFORMED:'Nate: Offsite BonrgsMelis Require Access Agreements or Encroachment Permits TYPE OF WEL1AKMG W4119F WSTALLATiON TYPE ❑ "ITORNG ❑ HOLLOW STEM BORING DEPTH 2025 R bgs ®BOLTED TRAFFIC BOX ❑STOVE PPE ❑ um4ACnoN rvA)m Yab1 ❑ WMMERDRNEN DIA of BOREHOLE 6 wxtm ❑MULTIPLE CASINGS❑wLTNINR HELL CASING DN ❑ SOL VAPOR PR(w _ _ NID ROTARY CASING THICKNESS _ TYPE OF cASa1G ❑STEEL ❑we ®OTHER HOPE ❑ SOL"NG ❑ PUSH PONT(GPI CPT) CONDJCTOR CASING ❑Yes 0 No Sixin Da_ Crrng m: _. C-N DW*L —..------- N @uECTHxr(,W Sy� 2 ❑ HRPD AUGER GROUT SEAL DEPTH 15 It b(js TRBiE TYPE TO BE USED ❑AUGERS ❑HOSE 0 PIFE ❑ OTHER _❑ OTHER: GROUT SEAL wbFfD' ED vas ❑No (Not Ir.a.,,,Fir+Dwh a 3 Fp Fm.,*n oI em bw*d WELLJ 90k BORING IDs HIN`h B reww)le oil GROUT SPECIFICATX)NS Grout mad to SICENO V!c6 at6tns rid t wwmd door hole__------ DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION 1ETHOD:fC1ECKALL THAT APPLY) 9 WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of indma to depth of bet WELL Ds ❑PRESSURE GROUT To doo offed beim axtam GROUT SPECIFICAT"S_ ------- - ---- -❑EXPLDSNES From to feet below surface TREME TYPE TO BE USED ❑AUGERS ❑HOSE ❑PPE ❑MUSHROOM CAP ❑3 fed below etrrlataa a fed below axfine%-3 led (COMhENTS: --� I hereby certify that 1 am authorized to complete this application and that the work will be dons in accordance wMr SaT,ioaquiy"my Ordinance Codes and Standards,and all other applicable Califomis bms. Signed.- -��ri�+-� /r//}l // _Tntelcon+ponY / (5) DA 'eiTZ C!cC/tS Print Name. �7'/�M Pc P� pets 1�U� --- Date_Irv_ ��LO 1 7 -------------- DEPARTWNT USE ONLY App4cation Accepted By,_ Date Issued: Grout InspecIlion BylDates: - Destuclion Inspection By/Dates: n FA N ame FA Address I I FAtt FA PE WP Reviewed By - ---- Work Plan Dale — ❑C-57 ❑Car Autwr..W tr O# .O SigPr A ❑WwWs Coop ❑V*rlr✓e Comp Waite ❑Erbnachim nt Perrot ❑Access Agreement ❑1-sW Agw"Aw mwel ❑NFR COItIIENTSJCONDITIDHS:------------ ----- - -- SIR TYPE PE SC FEE NFO AAn REMITTED CHECKi RECV'D BlY DATE SERVICE REQUESTS INVOIC" Pemtll 134 x EHD 29-0106-01-16 Site Mitigation Well Permit Application