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SANAMOUIN <br /> <br />Environmental Health Department <br />—COUNTY— <br />Gr a tness grows hero -a — <br />5] s rn CD <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />7:3 ...1-) 0 <br />For Wells and Borings Used for Contaminant Investigations and RemediatioK <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C=:0 <br />48 Hours Advance Notice Required For All Inspections • rri rc1/1) F <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. 10:11 This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County 1/n11 Standards. <br />Job Address k '61 504)414 A-krt nu City/State/Zip S loc.K vv/1 G4 cisaiv Phone 0301- g661 <br />vAuthl) APN (03 1196 n <br />Phone t o q-13-7-86/5-7 <br />Address <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />Cross Street IA) \ U\CiAtIA <br />Property Owner* Ct tk. NeN <br />Address LAW A ) L * i ROL;/- <br />C-57 Contractor c)Ai <br />Address 12.2o rti , Ects-\ 5.t-, • <br />Consultant/Sub-Contractor MAL/ ir4- 4L <br />GOIVIVA 014 14-551) <br />City/State/Zip Lklor 1521) <br />License# C10101q9 Phone c3D -&6(-34900 <br />City/State/Zip 4t )L4) 10'44 CA- 5'7b <br />License# Ro phon.73b—(07(/-24/z <br />City/State/Zip (41414,44 (1/—q54.3Z <br />Tv0E OF WELL/BORING NUMBER INSTALLATION TYPE <br />MONITORING 15( HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING -7„.. PUSH POINT (GP/ CPT) <br />INJECTION (Air Scam, Ozonel 0 HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note! Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS DP -1 Ao <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />Ei OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP p 3 feet below surface or feet below surface if >3 feet <br /> <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED CI AUGERS CI HOSE D PIPE <br /> <br />COMMENTS: <br /> <br />I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br />an Joaquin County Ordinance Codes and Standards, and allRther <br />Aj <br /> plicable California laws 1,, <br />Title/Company 1-)i\k f Naha. yzi, — 5t 5 FA, 1 n WI 4/11/6.15/14 ( <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />DEPARTMENT USE ONLY <br />, ) Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name ,,, -1--,-„, tc, , ., <br />' <br />FA Address t )i-1 1 S 1--,: i iv J._ FA# PR# - : d <br />FA PE , (1) WP Reviewed By ( _ V Work Plan Date <br />i <br />i 11) 0 C-57 C-57 Authorization for Other to Sign Permit 131Worker's Comp 0 Worker's Comp Waiver CiKncroachment Permit 0 Access Agreement 0 Lead Agency Approval aMFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit ,r):- ,K. v., -,' $152x ,I <br />$ 1")C1 `11(4A L-/ PI "hi <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application wive 1012.110 t Sle) 4 l• §1-Quit .1-90'5 s <br />Signed SA <br />Print Name Date