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Cross Street <br />Property Owner* <br />Address <br />C-57 Contractor <br />V al <br />Flo d <br />ED Jr. IA <br />Address 9.2D <br />Consultant/Sub-Contractor • <br />Address 33,30 (oft44/141/1 550 <br />N JOAQUIN RECEIV <br />NOV '2 1- 2017 r <br />ENVIRONMENTAL ARTIE MITIGATION WELL & BORING PERMIT APPLICATION <br />PERMIT/SERVIr& Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address sD,A4 FiNeoliti) 4r City/State/Zip Oikt U4 r--57/ -327 <br />20 -5/d9 <br /> <br />S/r Xh 11- 5-520 9 <br /> <br />ab 19 9 Phone 530—W-- 366 4 <br />oodtbuil, 0 75771 <br />6 7V71 Phone 5 - yo --‘97é'- <br />Come-k,o /4/ a -5-d,)7 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />NUMBER INSTALLATION TYPE CONSTRUCTION SP CIFICATIONS <br />0 HOLLOW STEM BORING DEPTH 1 0 BOLTED TRAFFIC BOX 0 STOVE PIPE _ <br /> 0 HAMMER/DRIVEN <br /> 0 . MUD ROTARY <br /> tg PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />IC HAND AUGER GROUT SEAL DEPTH 0 I TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE l'PIPE <br />GROUT SEAL PUMPED? Yes Odorvi(N=m Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />Environmental Health Department <br />COUNTY <br />75ke Phone <br />AP N gt3-00 — y <br />City/State/Zip <br />License# <br />City/State/Zip <br />License# <br />City/State/Zip <br />Phone <br />PE OF WELL/BORING <br />NONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION Ar Some, Ozonet <br />OTHER 0 OTHER: <br />WELL) SOIL BORING IDs f-a.A / Dal 6 <br />DIA. OF BOREHOLE -3 II 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br /> <br />AUGERS El HOSE 1:1 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />:I OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />12 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />SiJoaquin County Ordinance Codes and Standards. and all ot er anon ble California laws <br />Title/Company <br />Date 1 1 —I 7-- <br />Signed <br />Print Name 1 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates. <br />Facility/Site Information <br />Date Issued: <br /> <br />FA NameV,./.0.,(v...0/ /.2wr.4.4 7:414A.44.i FA Address / XI "7 7—"riti)AAA.7 FA# Oz).3 6 1P R# c 6 3 0 <br />FA PE ..„,..,- <br />7-1— ° <br />WP Reviewed By ,-- Work Plan Date - <br />K-'57 0 C-57 Authorization for Other to Sign Permit Et'Worker's Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement Ealead Agency Approval ''MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 740'1)1 ) $152 x 7 _..._ A 5oLi kiP(R) 7 6 9 i' <br />JA <br />868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />D 29-01 08-01-17 s roilcrry,611f;rpapiica5on