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Phone 20 LI6,0111-57 City/State/Zip ..CrOC. I,- to APN 155 I 0O 2- COMMENTS: Date Issued: Application Accepted By: Grout Inspection By/Dates: DEPARTMENT USE ONLY eOleletCre Site Mitigation Well Permit Application EHD 29-01 6-23-2015 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 HazeIton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com PERMIT/SERVICES 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 made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. kECEIVED MAR 1 6 2016 I 8 1 h 2- e ri five_ C-57 Contractor Address 3.3 oeV c c—,4-( Pr: Consultant/Sub-Contractor CO r r Fe,- k Address I I< We it- c.:f ..) Sre Phone 2413 4i -40578 City/State/Zip 5/1/4.1,- ro ,c4 95.206 Property Owner* Address 5;1 /1 tin c-4 Li A CO Writ it 520 W ie. r , LS City/State/Zip —5 The.-1(rOA/Co1 952.09 Licenselt 7zogaii City/State/Zip 5 bc LThi, 45-Z 5 Phone Zri*-/65 - Phone I-0:1)4W —7 70a CONSTRUCTION WORK TO BE PERFORMED: "'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS IX HOLLOW STEM BORING DEPTH 0 BOLTED TRAFFIC BOX 0 STOVE PIPE HAMMER/DRIVEN DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS 5-eh IFC TYPE OF CASING: 0 STEEL mt PVC 0 OTHER El PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE OTHER: GROUT SEAL PUMPED? .Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS 4 it 1)1 1 e ell'. e.,1-- 5 -10 JAI' on i WI re r DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 9 AUGERS 9 HOSE LI PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY). OVER-BORE DIAMETER of inches to depth of feet PRESSURE GROUT To depth of feet below surface 9 EXPLOSIVES From to feet below surface 9 MUSHROOM CAP 9 3 feet below surface or feet below surface if >3 feet I hereby certify that I am dpn• aquin )1 uthorized to complete this application and that the work will be done in accordance with dinance Codes and Standards, and all other applicable California laws. Title/Company -5-"it Of 6.o o Date 3465 SCI Destruction Inspection By/Dates: Facility/Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date 0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR COMMENTS/CONDITIONS: OA, vi,,-, ?Ile lc- et ,ykre. po.1-14,,d riea-4-reweivi- SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Z 90 3 5z ';' k --/ -5':-)e - 1 L)53 (Al lit 3J2//)(, Permit 29'/ .290/ 3/5 $130 x ." 1. 4,5-i, /415'2 CA/TK 3//t /Ii, f7T7ii‘:o5 Job Address Cross Street Signed Print Name License# MONITORING EXTRACTION (Vapor/Water) SOIL VAPOR PROBE SOIL BORING L INJECTION (Air Some, Ozone) OTHER WELU SOIL BORING IDs