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SAN JOAQUIN <br /> <br />Environment1 I Health Department <br />COUNTY — <br />Grecitnes crows her, <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For 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 />Iil -1 c-f)A\ -F(4)5aw <br />W , av.volm wdm <br />53-3c -7 , Job Address <br />Cross Street <br />Property Owner*FiL).1"2: <br />0 <br /> 50,1 1A5 <br />Address ql 41 <br />0 <br />\6v\ Vql\ni bil`rt <br />C-57 Contractor NOW* DA11.11 <br />Address 2..o 1\lorliA .ct54' 5-rett <br />Consultant/Sub-Contractor 5+ eiu E-1(111 1/•DrIMatl i 711,(1 <br />Address-331) Ca vvem P <br />/ <br />4, ( a, 5d, )-(' 15D <br />Phone <br />City/State/Zip SfOct 1Vv) <br />.1, 95'dO9 <br />License# Cib()Vli Phone <br />City/State/Zip (.slJOD4 (04 CA 95-7 71, <br />License# ?G1-fl 1 Phone 53044 -)4 7 <br />City/State/Zip &Kehl/ P.4) CA- 95;og <br />City/State/Zip 11)(ik km CA cl5Dpb Phone <br />APN <br />01-5/8 -39% <br />530-60-361D <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> <br />TYPE OF WELL/BORING NUMBER <br />MONITORING 3 o <br />EXTRACTION (Vapor/Water) <br />INJEC (Air Sorge. Ozone/ <br />0 OTHER <br />WELL/ SOIL BORING IDs 5 t-'2. <br />Dpi 13) <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />G2-71, <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes No <br />GROUT SPECIFICATIONS <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL OPVC 0 OTHER <br /> <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED CI AUGERS 0 HOSE CI PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />CI OVER-BORE <br /> <br />DIAMETER of inches to depth of feet <br />D PRESSURE GROUT To depth of feet below surface <br />cl EXPLOSIVES <br /> <br />From to feet below surface <br />CI MUSHROOM CAP <br /> <br />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 />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed Cdo,‘-\ f Title/Company PIDJ-42 illy - S-I,retk. Eiwirmvvikuid.i 7rte i <br />Date <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: IQ i <br /> <br />FA Name cm t r n,c1 FA Address t ill i 5. ,, ,Atis. <br /> fyi' — tno ii5JV , <br />FA# 1002;33 (0 li <br />PR# (54 08i q <br />FA PE <br />f )-1 (" 0 WP Reviewed By /_. ) Work Plan Date t/ /. <br />-7 LY /,, 7 <br />0 C-57 D'C:57 Authorization for Other to Sign Permit ErSorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval VMFR <br />COMMENTS/CONDITIONS: \-€4-,:k- <br />WP TYPE TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit ()$U -,•;- "'" 1) $152x A' ACID ‘12448 L- X l'thdi n vi 1°0051.5 3 2_ <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />e Qn.as .51. 4 -) uM• '-tztoyi 3-2-4 <br />Print Name