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SAN JOAQUIN COUNTY RECEIVE -.4 ENVIRONMENTAL HEALTH DEPARTMENT <br />1. 186 <br />i <br /> <br /> <br />8 Hazeiton Avenue, Stockton, CA 95205-6232 <br />Lill IA '41 <br />lall C MAY 3 1 2017 .. <br />,.. .... Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: vvw1-61L§i-c-e1441. itAilb N MENTAL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICATIONsEimEs <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 .2 1 I- (0—tt (to, q l sca , City/State/Zip i-A.t.i...,-. CI Phone <br />A° , <br />Cross Street <br />Property Owner` C DI 401 ei g.‘ r: J f f 5-411!/11 <br />Address 55/ )-a,c.:o Vt'11 4., 114 . n , i <br />C-57 Contractor fe s/ctik, <br />Address 5oci, gis o4ivtt. it, <br />Consultant/Sub-Contractor tr"rt_ ft <br />Address 611i /kr! • <br />APN <br />92)- -y223 <br />City/State/Zip W6 rt k ft s <br />License# Phone Off -116i <br />City/State/Zip welt f (4 IVO/ <br />License# 3 0;qs- Phone -)01-ti/C`cj)-7... <br />City/State/Zip 6't 01'Zi <br />ii <br />Phone <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORNG NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM BORING DEPTH I 2-' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE 0 EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA, OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTt-LEVEL WELL CASING DIA 0 SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER fil SOIL BORING ( CR PUSH POINT (OP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Din: Casing Depth• 0 INJECTION (Air sparge, Ozone) 0 HAND AUGER GROUT SEAL DEPTH TREMtE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE 0 OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No Note; Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IN GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br />0 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 0 3 feet below surface or feet below surface if >3 feet <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 Title/Company <br />Print Name Date <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FAlf PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Walter's Comp 0 Worker's Cornp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE* <br />Permit $139x <br />END 29-01 10-26-2015 <br />Site Mitigation Well Permit Application