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DEPARTMENT USE ONLY
<br />Application Accepted By:
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />Date Issued:
<br />P SANAAQUIN
<br />--COUNTY
<br />Environmental Health Department
<br />Greatness 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 />Job Address St e A4 1,4.4 F; •P') We l l` P i b ij City/State/Zip 17-K. c CA
<br />/c 24L IV, Auta-,
<br />City/State/Zip 7 .--re-e CA 9 T 34 4
<br />C-57 Contractor I /4 Cf 4 SJ 6-) CA 1: 4-..r ?.):- License# 40 6 5 S Phone 9 4' Z? 5.3
<br />City/State/Zip
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />TYPE OF WELLJBORING
<br />
<br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />MONITORING 0 HOLLOW STEM BORING DEPTH 5 - IC r r 0 BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />WELL/ SOIL BORING IDs SG 1-7' 1..r&t _s‘
<br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN
<br />SOIL BORING Isk PUSH POINT (GP/ CPT)
<br />INJECTION (Air Sparse, ozone/ 0 HAND AUGER
<br />OTHER 0 OTHER:
<br />SOIL VAPOR PROBE 6 0 MUD ROTARY
<br /> DIA. OF BOREHOLE I : :d4C 1.-4 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />CASING THICKNESS TYPE OF CASING: KSTEEL 0 PVC El OTHER Oi ir.ter r ,-..s I, ROA CO
<br />CONDUCTOR CASING 0 Yes ti'No Boring Dia: Casing Dia: Casing Depth:
<br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />GROUT SEAL PUMPED? 12 Yes Og'No (Not p: Maximum Freefall Depth is 30 Ft)
<br />GROUT SPECIFICATIONS p.i .1 •. t Ce_ vv., - -r" S / fir t -/ ( f ,,..el....A c,..----7 )
<br />Cross Street 4,0 f 0 Vet Vs: lp :Co RA i2i/PP,i44/0 eigri.1,,APN 24 0 - /40 - / c.)
<br />Property Owner* gUr A. 'N r••••,i'" LI,C
<br />Address
<br />Phone
<br /> A1/A
<br />Phone 2. o f 812-700c.
<br />Address i 1 3 O M 0 k
<br />Address 3C50 tu City/State/Zip
<br />Consultant/Sub-Contractor
<br /> IILe< i• I 0. A cSa t9.License#
<br />/CA 47E -4-'1 2-
<br /> Phone 2 I s/
<br />tv S'A er4: ls&17
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />WELL IDs
<br />GROUT SPECIFICATIONS
<br />TREMIE TYPE TO BE USED ['AUGERS 0 HOSE El PIPE
<br />DESTRUCTION METHOD: (CHECK ALL THAT APRLY1
<br />OVER-BORE
<br />
<br />DIAMETER of inches to depth of feet
<br />El PRESSURE GROUT To depth of feet below surface
<br />EXPLOSIVES
<br />
<br />From to feet below surface
<br />El MUSHROOM CAP
<br />
<br />El 3 feet below surface or feet below surface if >3 feet
<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 1 r 4'4 1- 1-"/'° " "1 A514 '
<br />Print Name M 4 4-4 1,e ,— A Date 9 I*
<br />FA Name n I is. ,r, jk b ciA ,A , 6, rk FA Address FA# ,;:47 2,5.1a0 g PR# cis,-Lts c.,..c.,
<br />FARE 5') WP Reviewed By
<br />1- X Work Plan Date af / k\--
<br />0 C-57 IEK-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 Aid' prove! ENTR
<br />COMMENTS/CONDITIONS: , ,,‘ udett t, eJA ipc. c,..„,....„( c..". to U....tix,_, 3Ak.1.6-0., 4.,,,A Ca j t y-tA
<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE#
<br />Permit 254,0 3-- 3 1 -. $152 x 3 q 4 q, _s-isc31 L-Y gi f sjik -,.:)(-- 0 V 3 i k-, S c/
<br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com
<br />END 29-01 08-01-17 Site Mitigation Well Permit Application
<br />C
<br />2
<br />O3 51_5 I 3 4 Lt sz rico I L- 5/1 k -,32-00995-01
<br />Signed
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