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Consultant/Sub-Contractor <br />Address <br />'RECEIVED <br />Job Address 1015 41111 11414 (404. City/State/Zip 5141644 01- 752D 41 <br />APN 5— N <br />rn <br />PR 2 7 2018 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />MENTAL IfEALI 11 <br />_PARTIMENT 1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjcehd.com <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 />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 />Phone qa -Y37-0 <br />Phone Y10:71371090 7 <br />City/State/Zip WOC(A 131-1613-e j C4 C(5). <br />City/State/Zip uitd 577h <br />License# P& 1'411 <br />City/State/Zip Carr./401YL /00A g5gz_ <br />Cross Street r 6 1 3' IA <br />111111‘ 1 Property Owner" , 4,MkrS 0 <br />Address _ _ 35. Cip,q5S RUA <br />C-57 Contractor Orj(ti 55)41-.00 <br />,— <br />License# Phone <br />Address <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />0 (ovl ec15IP <br />Phone 530 <br />TYPE OF VVELLJBORING NUMBER <br />C(MONITORING _1_51 <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />0 SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparge, ()zonal • HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs <br /> M <br />N'BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE $ ' " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS '2" TYPE OF CASING: 0 STEEL st PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes Ef No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH 2g i TREMIE TYPE TO BE USED: F AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes pi No (Note: Maxim m Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 1 a <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br /> <br />DOVER-BORE DIAMETER of inches to depth of feet <br /> Ll PRESSURE GROUT To depth of <br />EXPLOSIVES From to Ill <br />feet below surface <br />feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet LIAUGERS D HOSE D PIPE <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 />5 <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />0' Signed 131(LA <br />Print Name Sti` <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FA # PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 0-57 0 C-57 Authorization for Other to Sign Permit 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# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit $139x <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />, <br />Title/Company L <br />Date