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Address 303 T son Croonal Odds. &aa GOO <br />Address zev sone.' suon <br />Phone Job Address Douma R0:50 City/State/Zip Lalrano CA 95330 <br />Phone (650) 632.4522 Property Owner Szylacok Ci5P. LiC <br />C-S7 Contractor co,r1.-40 Licenser/ 9131s4 Phone (9i0)760-mii <br />City/State/Zip Saorarnonto. CA 951321 Address 3309 El Cam= Avo. Sacto 300 /148 <br />Consultant/Sub-Contractor Hyr9dFddAs. lo Licenser/ phone (530)759-20a <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Watet) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />liCECTION (Air Q02,142 Ozcou <br />OTHER <br />tal_g3 B INSTALLATION TYPE <br />119 HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PuSH POINT rcer cFr) <br />HAND AUGER <br />OTHEFL <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION WORK TO BE PERFORMED: <br />N WELLS TO BE DESTROYED <br />WELL !Ds <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />13 OVER-BORE DIAMETER of inches to depth ol feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 03 feet below surface or feel below surface if >3 feet <br />Date 2r25r12 Print Nartlé Josh K51n2 <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dales: <br />El-ID 29-01 6-23-2015 Site Mitigation Well Permit Application <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: ww_v_i,licenci.00 <br />HEALTH <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIORMOVERocEs <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 desc,ribed. <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 />Cross Street Sdas Mar:Shay Road APN 191.220.13 <br />N'ECEiva) <br />AUG 0? 21 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Weils Require Access Agreements or Encroachment Permits <br />WEUJ SOIL BORING IDs cise-12 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 21 0 BOLTED TRAFFIC BOX al STOVE PIPE <br /> <br />A. OF BOREHOLE 10 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA 4' <br />CASING THICKNESS TYPE OF CASING 0 STEEL al PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes (11 RO Boons Da: Casing Caung (*PM <br />GROUT SEAL DEPTH loll TREME TYPE TO BE USED: IN AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes No (Note: Maximum Freetall Depth is 30 Ft) <br />GROUT SPECIFICATIONS now smart sardary soai • 10 <br />505 tonal 211 boatowlo trassaaan 6041 bat.. Sanaary seal <br />COMMENTS: <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 Conflaanco Inc <br />DEPARTMENT USE ONLY <br />FA Name FA Address I I FM I I PRO <br />FA PE WP Reviewed By I Work Plan Dale I <br />0 C-57 0 C-57 AtAtictizatice tor Other 0 Sign Pertrut 0 Worker's Comp 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# RECl/D BY DATE SERVICE REQUEST 33 INVOICE# <br />Work Plan <br />Permit $130x <br />Signed <br />City/State/Zip sw.od sh.o. CA. 94055 <br />City/State/Zip 0svrs CA %Oa