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RECEIVED <br />SANAAQUIN Environmental Health Doppttfro t <br />tI <br />--COUNTY <br />CretI5c grOWr. <br />ENVIRONMENTAL HEALTH PERmIT/SERvicEs <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <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 91)51 S , El Oe 5+ City/State/Zip Sio(tm (A 9594 <br />Cross Street MI; Si, tA IA) 41/41 St APN IL/ 5 -153 -61 <br />n <br />vA) <br />Address 5330 (Avywly‘ <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLJBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONp,,vometJ auP <br />0 MONITORING 0 HOLLOW STEM BORING DEPTH i 25' (.P1) to ip BOLTED TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE ') — Li IT 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE „ 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />lia SOIL BORING I im,E5 PUSH POINT (GP/ CPT) CONDUCTOR CASING ID Yes0 No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION Air Spam, Ozonel SAE EA HAND AUGER GROUT SEAL DEPTH ce, 144.-iTAVAIE TYPE TO BE USED: El AUGERS CI HOSE 0 PIPE <br /> El OTHER OTHER: GROUT SEAL PUMPED? _Yes No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs (p-r-g,C, 14A-11 1447 Z- .1 <br />GROUT SPECIFICATIONS fte (1yytirti <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />1=I MUSHROOM CAP 1=I 3 feet below surface or feet below surface if >3 feet <br /> <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ClAUGERS 1:1 HOSE 12 PIPE <br /> <br />COMMENTS: <br />Property Owner* ilia vjkttfte Mt ilftl , 501 1 <br />I a . <br />Address (43uo Je5skci CA rriu <br />C-57 Contractor (ft -, eci5 11 <br />150 i Lea /LP I <br />Consultant/Sub-Contractor S <br />Address <br />City/State/Zip Fr-t incyti, 64 c/1 /41555 <br />License# Phone <br />City/State/Zip <br />License# <br />City/State/Zip <br />Phone M-4 5 1-4 4 <br />Phone Urt- 51-4 '(0 <br />Phone 5 36) v7f-2thz <br />6,8 <br />575-513-5ke, <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 allther ap • licable California laws. p <br />Title/Company ill q <br />Date <br />Signed <br />Print Name <br />54- <br />8.-1—irgr\ <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates <br />Facility/Site Information <br />DEPARTMENT USE ONLY <br /> ate Issued: \\•1 iO) <br />'fh <br />I <br />I 1_I//i )(1 <br />FA Name 6 v.., iA.- —1, - .00,(1L .tX a_. FA Address 2_05 1 ..,-i,-1A4 SV• FM c,,k. .2...m 3 ..1, I PR# <br />FA PE D.-9t li C% WP Reviewed By I-, —>< Work Plan Date ,s-it 6 i -2 i *1 , <br />0 C-57 Er•C‘-57 Authorization for Other to Sign Permit Illorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement ritead Agency Approval Ei:FR <br />i <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit ,f-.:1, c '7, 1 '> $152x , A. ,--,L:,L> L )4 \\\1,1 <br />1868 E. E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />s 51 z_)k- <br />L t L )k St-00 .-qi,L(LikA