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Consultant/Sub-Contractor <br />Address 1333 Gime!, <br />REC'D MAY 1 5 2018 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />C OUNTY <br />Grc.J riess grows here. <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 />i Cross Street APN 015 /23031 IA t cAA <br />Property Owner Stej , LP 6-Faivic)4,4,1 5x,))„,,,,,,,,5k,(.4,44; Phone 1-166 — )37- e7e/ <br />Address V% O !Ix City/State/Zip W4:::.1.1 AVY ja <br />License# Cl(k 7i/ ri 1 Phone <br />City/StatelZA? IMJCPeefri 4.5-770 <br />s/iA ovitik) J(7L/77 (.56‘) ,61 )-htii,) Phone .5 4-1;Z. <br />5,56 City/State/Zip 61 4.15Z; <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TY E OF WELLJBORING NUMBER <br />MONITORING <br />El EXTRACTION (Vapor/Water) <br />El SOIL VAPOR PROBE <br />El SOIL BORING <br />E] INJECTION (Sir Spa-qa, Ozone' <br />El OTHER <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS g HOLLOW STEM BORING DEPTH 1 tXBOLTED TRAFFIC BOX <br />HAMMERIDRIVEN DIA. OF BOREHOLE I 1 <br />0 STOVE PIPE <br />El MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br />MUD ROTARY CASING THICKNESS 3 I ' TYPE OF CASING: El STEEL*PVC El OTHER <br />1:1 PUSH POINT (GPI CPT) CONDUCTOR CASING El Yes tgNo Boring Del: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH Q 7 I TREMIE TYPE TO BE USED: El AUGERS CI HOSE 0 PIPE <br />El OTHER: GROUT SEAL PUMPED? El Yes 'V No (.(4N4o;i:zialmum Freefall Depth is 30 it)..c.44,411 <br />GROUT SPECIFICATIONS f‘t 4 ) i, 11, , 5q, <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br /> <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED P AUGERS D HOSE 0 PIPE <br /> <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 />Joaquin County Ordinance Codes and Standards, anti all oA,er applicabit California laws. <br /> Title/Company P/14,5-e'd irly• SW/5 gçu-•sij <br /> Dat,515/5 <br /> <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />/1 / <br /> <br />FA Name RwirA vvx.f., to 4 •It.t FA Address -t-t Li..-,., vs, i _t..., . Fatt 002liacq PR# ac- i 3Q::-.3 <br />FA PE / too WP Reviewed By 4._ .Al Work Plan Date ? /7 <br />El C-57 Ell C-57 Authorization for Other to Sign Permit Et Worker's Comp El Worker's Comp Waiver El Encroachment Perrnit 0 Access Agreement El Lead Agency Approval :KM <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit $152 x l 4IC2- , <br />1868 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 . .j Mitigation Well Permit Application <br />4 e 2_40; ,-> 4 cs2.. x 3 ilLst,i 164 <br />Job Address IC b LU . A LCIO cSit•C i Phone 24 City/State/Zip <br />C-57 Contractor peAe aiA Di; r tf) <br />Address 111130 at, F-11-51 51 <br />Signed <br />Print Name