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RE ce ver)
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />1868 Hazelton Avenue, Stockton, CA 95205-6232
<br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slcehd.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 />Job Address 0 2, . City/Stato/Zip 47r1D6V--fri./t CA 4131,0 (P hone pitic
<br />Cross Street FYI-PT44-4.-10-/ PtN/V . APN 1)A - 05‘
<br />Property Owner' KO- • mitylAr•-- s pg-k Phone V"/-
<br />Address /r1r W tr-i914-Pr-P", • City/State/Zip ‹.roc,t4--row, cp.- A -2-c)
<br />C-57 Contractor Co.sco..0 6 p e_tuA,A1.1- License# CI 221f Phone S-3C/ 24.2- 5
<br />Address 1A(01 kaRcia, Avg City/State/Zip Gt-htl Om° GIL t4
<br />JUN 1.111,,.
<br />ENVIRONMENTAL HEALTH
<br />PERMIT/SERVICES
<br />Consultant/Sub-Contractor cryvocV7-- License# Phone
<br />Address iss-15" L-05. &Om) . City/State/Zip LDS
<br />CONSTRUCTION WORK TO BE PERFORMED: 'Note. Offsile Borings/Wells Require Access Agreements or Encroachment Permits
<br />TYPE OF WELL/BORING NUMBER
<br />g MONITORING
<br />ExTRACTION(VaporANater) 0
<br />0 SOIL VAPOR PROBE
<br />ID SOIL BORING
<br />INJECTION 04_ Spam, Ozonel
<br />OTHER
<br />WELL IDs
<br />GROUT SPECIFICATIONS
<br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />HOLLOW STEM BORING DEPTH cEj
<br />HAMMER/DRIVEN CIA OF BOREHOLE s
<br />MUD ROTARY CASING THICKNESS 104 S O
<br />PUSH POINT (GP) CPT) CONDUCTOR CASING Yes El No
<br />HAND AUGER GROUT SEAL DEPTH iNo
<br />OTHER;
<br />WELU SOIL BORING IDs MU/ '02), - ?, GROUT SPECIFICATIONS
<br />- rig
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED
<br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE
<br />a BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />TYPE OF CASING: 0 STEEL DTPVC 0 OTHER
<br />Bobs Eta: " Casing Eta: /0 " casing Depth: ro •
<br />G-64 ,Oet-t rvel.
<br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />GROUT SEAL PUMPED? 0 Yes ZI No (Note: Maximum Freelall Depth Is 30 Ft)
<br />PL-114.— c_
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY)
<br />
<br />12 OVER-BORE DIAMETER of
<br />
<br />inches to depth of feet
<br />1:1 PRESSURE GROUT To depth of feet below surface
<br />El EXPLOSIVESFrom to feet below surface
<br />13 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feel
<br />COMMENTS:
<br />I hereby certify that I am authorized to complete this application and that the work will bo done In accordance with
<br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws.
<br />Signed
<br />
<br /> Title/Company 1;116,31,-/ I <13/4 Z-01/414c r'/<TPIINJ TV 1—
<br />r- ¼Jt.J Date
<br />
<br />Print Name
<br />
<br />EP ENT USE ONLY
<br />Application Accepted By:
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />FacIIitvISlto Information
<br />
<br />Date Issued: 7
<br />
<br />FA Name rt-k' (orefelsvire," SAK.A k /Ft iy; FA Address It. i IC CourvvitY1) C ‘'4 FM . 'IC'?" L'i I g 3 L, ' , PR# 1..c.4 4' 2 - 1 C '7
<br />FA PE 2 '1 SO
<br />WP Reviewed By
<br />ifittelti
<br />L - X Work Plan Date 10 1(6, hi;
<br />C•57 0 C-57Authorlzation for Other to Sign Permit Wakes Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Acce s Agreement tato Agency Approval
<br />COMMENTS/CONDITIONS: .-V ,A4 kl,.,A“., to,„. 1 -,,L. -Art, tit.ce—.•,,...,,,,,k--,01(1,.. -1/4-_,L,,ANc c i-o 1-1-4._ levAl-un,%. 0-P, klo-li- 4...44-4A -4-1""vvo `A-5 il. 4, .4tA.--)-w.e_....`, Tla,t.e.., 1..r.:21**.I.- 46 L.-.0,...kA kli-, (..,1 ',Lk-v./v.04_1r 1.L.,,i a ,s.e,..5e A - A- Ve A- "--te ity" -_,„ v .. \ c.ot., -), • ,----,.. .,.' .7-7, .- cp. 1..v ...-..-k. 1: ...-....% e _.,„,f-,._>, •
<br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REtV'D BY DATE SERVICE REQUEST# INVOICE#
<br />Permit 1.....c -oc i 3 0 4 ke,-cl , 53c.i‘i, wa-ix ot 1----X 1111-1 1,,,.; rooil--oz‘
<br />Site Mitigation Well Permit Application END 29-01 10-26-2015
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