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SAN JOAQUIN Environmental Health Department <br />City/State/Zip Address 1135-0 Mo.;er k <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 5 - 0 Fr <br />DIA. OF BOREHOLE I c <br />CASING THICKNESS <br />CONDUCTOR CASING 0 YesX No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED?. 0 Yes A(No <br />GROUT SPECIFICATIONS hi t 4 <br />TYPE OF WELLJBORING NUMBER INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />1:1 EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />X SOIL VAPOR PROBE J 3 0 MUD ROTARY <br />0 SOIL BORING _XI PUSH POINT (GP/ CPT) <br />El INJECTION (Air Sortie, Ozone) El HAND AUGER <br />o OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs 5 C 7 e s- C)/ <br />El BOLTED TRAFFIC BOX ID STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: XSTEEL 0 PVC 0 OTHER 7); Pe 41- All ft" 1 <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />dr 11.,, ( p,,- 4 it VI <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: VW) QJ4.A <br />Destruction Inspection By/Dates: <br />COUNTY <br />Greotnesc ‘7roves hPre <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 S t A 4 -i-e. c Lt.( F:j vie .1") (A•741 1 /4 P 1 s' City/State/Zip 1—rs- C C A <br />Cross Street 140 r sjo I/4 r RA 4.21req.lisb AcV,7:2•ApN 2cz 0 - 0 - 4 SD <br />Property Owner* Sarl A. de( Co lust".."'' '4'4'e .5, L 1, C <br />Address /o 2s,4- 10, C t ., A. I FN Ut sh)a c_ <br />C-57 Contractor -r- a /4 kit" CA iJs License# <br />Consultant/Sub-Contractor 14) 4 II 444 °. se e: teiLicense# <br />Address 30 50 g t City/State/Zip <br />City/State/Zip j <br />Phone <br />344 <br />0 6 5 Phone 9/4 R 53 C)1C' <br />RA.wcka CorIWA /CA 1°S-4 4i 2. <br /> <br />Phone 9/4 1'7 2 4-7V <br />.S c lc 4-, CA 6956f/ <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />0 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 />COMMENTS: <br />Title/COMparly i)/ e 61." 71.74f I) t! • k a," <br />Print Name Alt a +.-k e- <br />ft' <br />.-• A . -1 A Date ( / <br />DEPARTMENT USE ONLY <br />FA Name k„... \, vs. culocti, u IA. t.o.,1 FA Address FA# e00-2>lirt9 PR# orti .3 est, <br />FA PE eg10 WP Reviewed By L — .N( <br />Work Plan Date floritir <br />Agency Approval traR 0 C-57 reCc Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead <br />COMMENTS/CONDITIONS: 50, ‘ (.,.1/4,101 3 (..a.A4 k, pup4..t.ae v...... flA4A,,.- c(- ,_.o( ei---ck C,i,/er-c41 <br />a , 0.044 t SCL9e.i.4 co , 3 ie—al <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECY'D BY DATE WELL PERMIT# INVOICE# <br />Permit <br />_ <br />710S <br />. <br />3)3 $152 x 3 i 1 4S-6 S1c031 L----X 8115 11S, Wee)0300C0 <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 Site Mitigation Well Permit Application <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 />Signed <br />Phone <br />Phone 20- 832 - I ooD