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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazetton Avenue, Stockton, CA 95205-6232 1,'1A11 1 2017 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: <br />www.sicehcW-NMENTAL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICATIONsERnEs <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 />7- S11 ( (tvi, (x/4. City/State/Zip (1 Phone <br />f <br />APN <br />RECEIVED <br />Job Address <br />Cross Street <br />t ftb <br />... ig bit <br />Property Owner* C rAt r:Vti Phone 12 )- _ 13'r -g22.3 <br /> <br />Address 5 5 1 kii(),4e,:o .11i, 11 4 P.-4 City/State/Zip VA^ (.4 <br />A <br />C-57 Contractor (9 ibtttl,_ <br />Address 1)ti O ft,ti5+ <br />Consultant/Sub-Contractor et <br />Address 61s1 Atri <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />License/ Phone qq, b)1 <br />City/State/Zip weyt I . CA /5V, <br />Licensed <br />city/state/zip OLT , ( q0L <br />Phone 1/4.12t-c;r z. <br /> <br />TYPE OF WELL/BORNG <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />El SOIL BORING <br />INJECTION irw Same, Ozone) <br />OTHER <br />WELL/ SOIL BORING Ds <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 HOLLOW STEM BORING DEPTH I 2.' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULULEVEL WELL CASING DIA <br /> 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />I ija PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Die: Casing Dia: Casing Depth: <br /> 0 HAND AUGER GROUT SEAL DEPTH TREME TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> 0 OTHER: ..............___ GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />0 AUGERS 0 HOSE 0 PIPE <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 />EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 03 feet below surface or feet below surface if >3 feel <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br />COMMENTS: <br />Signed <br /> <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 /> Title/Company <br />Date <br /> <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />FA Name FA Address FA# 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 Cornp 0 Worker's Comp 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# RECVM BY DATE SERVICE REQUEST# INVOICE# <br />Permit $139x <br />El-ID 29-01 10-26-2015 <br />Site Mitigation Well Permit Application