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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siceh.d..cani <br />NA/ Ku IN MENTAL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICAMOttsERWCES <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 />.5 "II (04,t i Job Address <br />Cross Street <br />1K . Property Owner* Col .6"ga E:ati <br />TREM1E TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />Boring Eta: Casing Dia: Casing Depth: <br />TYPE OF WELL/BORING <br />o MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />Ea SOIL BORING <br />INJECTION (Air Spam Ozone) <br />0 OTHER <br />WELL/ SOIL BORING Ds <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH I <br />DIk OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> a PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br /> 0 OTHER: <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI•LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Date Print Name <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />END 29-01 10-26-2015 Site Mitigation Well Permit Application <br />City/State/Zip V" itfe („4 <br />License# <br />City/State/Zip Vrifyt tu , CA /51A I <br />License# 3 0) ‘4 <br />City/State/Zip .tn , 04*- (It f <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: OffsIte Borings/Wells Require Access Agreements or Encroachment Permits <br />RECINE <br />4y H 20i7 <br />City/State/Zip Sto(Ft*,,, Phone <br />Phone <br />Phone <br />Phone <br />APN <br />,ip <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />EI 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 />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <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 />DEPARTMENT USE ONLY <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FM PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Enomaohment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit $139x <br />Address 551 s ?5 -,4L :o <br />C-57 Contractor I al( <br />Address 1)b c'‘, as 0464-1‘ 5+ , <br />Consultant/Sub-Contractor ke."'T-t. et <br />Address 611i /4 if I, <br />t), <br />- -Sz <br />qi b - I L <br />"14 -1'21 ••• oj.)-2„.