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SANAOAQUIN —COUNTY GreeneSS orow ic here. Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Date Issued: I 1 /1//7 / rz i 5 1 -1 1 y///J /-1 RECENED Environmental Healng)07;17ment 20 ENVIRONMENTAL HEALTH PERANRVICES SITE MITIGATION WELL & BORING PERMIT APPLICATIO I For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address ).0i-t Ci SCWI JOCt Lit I ll 91 Cross Street 1,41 )11 Si Property Owner* F; -Iiilvi,,) cc dfics,, G., A11124'icet Address )...0\-tC1 5 t C)A4A -TO LI ViNv1 . '.34' i C-57 Contractor Ge.C-f) bl'Iti e)il CJI-1 1 '150 .1.0,4R,..Aq Consultant/Sub-Contractor --Y1 riu 5 Etiwybyt ivlavti-d ) iivt-c, r Address Address 333b cekvyu livon tv44 tt 55o City/State/Zip joittiii, CA 95 Z0 / License# kt 3 I b Phone ci Z5 -3/5 -55 11 C' City/State/Zip i C1114 Z (A Y 55 3 / Phone City/State/Zip GI MAO/ /Mk' C4 q9,23 ii7 License# / 4-1-7 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING N MONITORING EXTRACTION (VaporAlVater) SOIL VAPOR PROBE SOIL BORING 0 INJECTION (Air Spam. Ozonel OTHER WELL/ SOIL BORING IDs C7F73-4-- UMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ID HOLLOW STEM BORING DEPTH \2D I 0 BOLTED TRAFFIC BOX 0 STOVE PIPE HAMMER/DRIVEN DIA. OF BOREHOLE a ,, a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER kiClg PUSH POINT (GP/ CPT) CONDUCTOR CASING Yes 0 No HAND AUGER GROUT SEAL DEPTH GROUT SEAL PUMPED? Yes ID No q OThr,ER: I g c‘/-1---A-65 GROUT SPECIFICATIONS NO Cimunt Boring Dia: Casing Dia: Casing Depth: TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE ErkPIPE (N te: Maximum Freefall Depth is 30 Ft) DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 0 OVER-BORE DIAMETER of inches to depth of feet 0 PRESSURE GROUT To depth of feet below surface 0 EXPLOSIVES From to feet below surface 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all o/i er applicable Califo nia laws. ll Title/Company AO) ed /115V, 6 - 7 q 7 7- CLL ,_s i2-171k, Pkv, Date it) 3 I-I -7 Signed Print Name (1161- 5(AM r);- DEPARTMENT USE ONLY . __.....,. FA Address zAD 57S Crn C),:, ..c.,j,t, :71- FA# i ,,:.,z LI 3,/ i PR# FA PE PE ..--‘11 (P ° WP Reviewed By I- -) Work Plan Date i / 1.101 1 ID C-57 Et'C-57 Authonzation for Other to Sign Permit Et Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit n<cess Agreement WiLead Agency Approval 1:1'1IFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELLTPERMIT# INVOICE# Permit AciS ,l)\> $152x C 4-‘• A •)le 4 L -61', L. Y1 /4. \AV1.01 1 -1 kde 00 31tz;-; ,, 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application "17"i0 St. 001tWALk City/State/Zip S hq,P.61,) CA- C)52,0(0 Phone APN I 61— 'isc.)--c)3 7 _ )24 -1q "5'51 Phone