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DESTRUC 0 <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED AUGERS HOSE 0 PIPE <br />WORK 0 BE PERFORMED: <br />Job Address 00 Lovl R0a6 <br />Cross Street •seon mencrey Roan <br />Property Owner &more* CLSP. LLC <br />Address SCO Two Do;ko Orwo. SUMO 600 <br />C-57 Contractor codb....s......v.AtAl. tn. <br />Address xce A.. so. 300 1,48 <br />ConsultanUSub-Contractor Honfocia <br />Address 2an &Wow Sisoct <br />CONST <br /> <br />irflflN WORKOE P <br />nri—QE"-QM <br />BillitLIAB211LEE <br />Taitigggrf—MiEMEIC"—_. fflIMfi <br />al MONITORING HOLLOW S'IEN BORING DEPTH 2 t 0 BOLTED TRAFFIC e0x 8 <br />HAMMER/DRIVEN <br />EXTRACTION (VaporMater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />ttactON teidoolar2021 <br />0 OTHER <br />WELL/ SOIL BORING IDs CLSP-12 <br />ATIONS STOVE PIPE <br />OIA OF BOREHOLE to 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIP. 4' <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 33 PVC 0 OTHER <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:wwv___JL51911--id.c0m AUG 01 21)" <br />inty Well Standards. <br />BORING PERMIT APPLICATION <br />Figill$MERViC <br />This application is made In compliance with S8rIJoaquin County Development Title. Chapter 9-1115.3, and the San Joaquin <br />SITE MITIGATION WELL & <br />NO -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> COL <br />For Wells and Borings Used for Contaminant Investigations and RemedillignillailarAL <br />HEALTH <br />Application is hereby made to San Joaquin County for a perrnit to construct and/or install the work described. <br />City/State/Zip sssso Phone <br />AP N 19I-220-13 <br />PUSH POINT (GPI CYD CONDUCTOR CASING 0 <br />Yes gi No Bo nng De. Casing Dia: Ca:4m Depth: <br />HAND AUGER GROUT SEAL DEPTH io n TREME TYPE TO BE USED. iii AUGERS 0 HOSE 0 PIPE <br />OTHER: GROUT SEAL PUMPED? 0 Yes RI No (Note: ?awn= Fiaelas Deem is 30 Ft) <br />GROUT SPECIFICATIONS 04,01.0mo,160floo, 00cP • 100 <br />octfitioned 2 fl batitortio Lonsion saal boor <br />samary fool <br />City/State/Zip Redwood swot, CA. 94065 <br />License#213104 <br />CitylStatelZip scoamo,do.cA 95s2 , <br />LicenseN <br />CityfState/Zip Dora, CA 05818 <br />ORMED: 'Note: Ofisite BoringsNVells Require <br />Access Agreements or Encroachment Permits <br />DES RUCIION P`)D-.j-4.6---.6X11E°( <br />0 OVER-BORE DIAMETER of <br />0 PRESSURE GROUT To depth of <br />0 EXPLOSIVES From <br />MUSHROOM CAP 03 feet below surf <br />THAT AP <br />inches to depth of <br />feet below surface <br />to feel below surface <br />ace or feet below surface if >3 feet <br />RECEIVE() <br />Phone 16500324522 <br />Phone (915)7604641 <br />Phone IS-10062-240a <br />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 <br />Print Na kerns <br />eEPA_Ilt1 Mal—a-U.1SE ° <br />Title/Company CoolIoo00O. Inc <br />Date 7/25/17 <br />Date Issued: <br />Application Accepted By: <br />Grout Inspection ByiDateS: <br />DestruCtieri Inspection By/Dates: <br />a ' <br />0 C-57 1:3 CAT Autboruaoon for Other to Sign Penna 0 Wellies Como <br />E3 wcino's Com Waiver 0 Encroactrneni PO= 0 Access iv/wowed 0 Lead Agency Appece4 MFR 0 <br />Site Mitigation Well Permit Application <br />END 29-01 6-23-2015