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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness grows here, <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 />Job Address 1)(2s 50A\ T-riOnD A-vt nuc <br />Cross Street W UVAAA (A) (1 if tA(ii 6) <br />Property Owner* l....i rt tiS lock tim <br />Address LA00 'e#4 Of‘ I A <br />C-57 Contractor Y-0(011 c);1‘lly <br />q37g661 <br />A q-133-8415-7 <br />--‘1,(-36;CD <br />City/State/Zip 5 6.1C1011 (../4 cisado <br />1(13-066- \-1 APN <br />Phone <br />Phone <br />/ <br />City/State/Zip lo ‘,1(10) , 01- 15202, <br />License# CfNiSq9 Phone <br />Address 22o tv , ex4A city/state/zip 4tWc4jImel (A- q5r7t2 <br />Consultant/Sub-Contractor Si- S tilliitb(Alkywthj)-titit , License# Ro 1 14-n Phone ) -3(.) -(e) 7& <br />C <br />-24-0- <br />4vtum. v3- Address -...336 C40-0141P4—On It-55D City/State/Zip Av14- 0 '7'54il <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />z,tctlifx(h *el 5 rewv\ TYPE OF WELL/BORING NUMBER INSTALLATION TYPE <br />QgsMONITORING 2.t',5 HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />. SOIL BORING _ 1% PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparse, Ozonel 0 HAND AUGER <br />OTHER 0 °THEP' <br />WELL/ SOIL BORING IDs fAk)-k7.1 tylVJ -0 <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 o <br />GROUT SPECIFICATIONS (ki) <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: U STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: U AUGERS 0 HOSE 0 PIPE <br />Freetall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS El HOSE El PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />ID OVER-BORE DIAMETER of inches to depth of feet <br />l PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />l MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />Signed <br />Print Name <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 applicable California laws, <br />Title/Company P4i;J:ej NeVikap — s Uj ) jizit\-L1)114 , <br />i 0-3-11 5a Date <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />76 <br /> <br />Date Issued: I -' <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name ro-rww../ 6vvrva e-1 fruti4z-tiN5 <br />FA FA Address i .-, <br />l <br />v <br />a 1 I S f-re-SK Alit-4-- <br />FA# '., ... V I PR" QS-ti OgiC7 <br />FA PE ?e l 0 C WP Reviewed By 1_, )(- Work Plan Date 9 iz ti I, ....7 <br />0 C-57 IiC-57 Authorization for Other to Sign Permit 2/Worker's Comp 0 Worker's Comp Waiver 2/Encroachment Permit 0 Access Agreement 0 Lead Agency Approval IlraFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit act, k -3 13 $152x )_. j 3 i Li 1.4t1 ).-))1g1 v•irc,> , t <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />El-ID 29-01 08-01-17 Site Mitigation Well Permit Application <br />?si as A K--1-$-) L--)c 111111 (,v_oelV 3