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SAN JOAQUIN Environmental Health Department
<br />TYPE OF WELUBORING
<br />0 MONITORING
<br />Ot EXTRACTION (Vapck'Na;eQ
<br />ID SOIL VAPOR PROBE
<br />CI SOIL BORING
<br />U INJECTION (A, sparoA Ozon.k)
<br />o OTHER
<br />WELL/SOIL BORING IDs SL
<br />NUMBER INSTALLATION TYPE
<br />EJ HOLLOW STEM
<br />HAMMERJORIVEN
<br /> 0 MUD ROTARY
<br /> IN PUSH POINT (GP/ CPT)
<br /> o HAND AUGER
<br />ID OTHER.
<br />la - lb
<br />irow,1 to ,
<br />CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH es; #elie 0 BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />DIA. OF BOREHOlE 44 '''' 0 MU_TIPLE CASINGS ID MULTI-LEVEL WELL CASING DIA
<br />CASING THICKNESS n b A f.- TYPE OF CASING' 0 STEEL ID PC 0 OTHER
<br />CONDUCTOR CASING ID Yes 0 No Boring Dia: Caslng Da: Cwing Dont-
<br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes 0 No Note Maornum Fractal! Depth is 30 Ft)
<br />GROUT SPECIFICATIONS
<br />wck1s
<br />vitt r
<br />COMMENTS: ,j„. k dykS 1.-PC r
<br /> Ce
<br />Application Accepted By: Date Issued: I) I ct- z,„,e 4114a
<br />DEPARTMENT USE ONLY
<br />.icl/t4
<br />Grout Inspection By/Dates
<br />TkA,J.L.‘,:tk-e Work Plan Dale r
<br />WP TYPE PE SC FEE INFO
<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 e.ev-tt: .,- c-\\ P 2\r`K, oj 0.,i City/State/Zip '-te.,.\,..:,,, ,Otcusl< , LA l'' k Phone Ct25 - /SI+. -1 -c15
<br />Cross Street APN ?OA - C (4a0— cairs- 52:5
<br />Property Owner eekt4vki1 Corten ,v1:41,es - le-cr 3,‘,0,,,,{
<br />Phone ql-s - 239 -
<br />Address ci cA Alywuk...., c4.0.-J s,.k.k. two
<br />
<br />1 . CIty/State/Zip Soon 3ese , 4,A, CISIIS
<br />C-57 Contractor PeneCore Drilling, Inc. License# 906899 Phone 530-661-3600
<br />Address 220 N East St
<br />City/State/Zip Woodiand,CA 95776
<br />Consultant/Sub-Contractor
<br />Address
<br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsile BoringsANells Require Access Agreements or Encroachment Permits
<br />City/State/Zip
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY'
<br />DOVER-BORE DIAMETER of 16 inches to depth of 3 feet
<br /> El PRESSURE GROUT To depth of 1 feet below surface
<br /> ID EXPLOSIVES From to feel below surface
<br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet
<br />e4 s -r<c%p ,,, 56-9, %.4-10
<br />0. \- to -f4c1- .•;1- tor 5 1-1-/o r 5(f/o'
<br />I hereby certify that I am authorized to complete this application and that the work will be done In accordance with
<br />Signed
<br />an Joaquin County Ordinance Codes and Standards, and all other applicable Callfornla laws.
<br />Title/Company -C 444' 5-Colo144 E N6E0 I.
<br />Print Narp Cod1 .30h4S11,‘ Dale il(cli2.0rig
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />FA Name
<br />FA PE
<br />cfit 0.57 pC.57 Authorlation for Other to S,gn Perm,'
<br />COMMENTS/CONDIT1ONS:
<br />VC V? 310 -Rd
<br />Worker's Comp 0 worker s comp Waiver 0 Encroachment Persia 0 Acce,>s Agreement 0 Lead Agency Approval 0 MFR
<br />osovu-6
<br />WP Reyiewec By
<br />FA Address FA#
<br />Permit 1D5.- 13 $152 x 3
<br />EA)9(b -c1 L9
<br />1868 E. Hazelton Avenue I Stockton California 95205 I T 209 468-342C I F 209 464-0138 I www sjcelid corn EI-10 29-01 08-01-17 Sie tilibgat,on We Perm.' Application
<br />AMT REMITTED
<br />45(0.0
<br />CHECK# RECV'D BY DATE WELL PERMIT# INVOICE#
<br />b079,_y ci 9 zct 03
<br /> LIcense# Phone
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED 12 soil gas wells to be destroyed
<br />WELL IDs SG 5-10, 5' and 10'
<br />GROUT SPECIFICATIONS
<br />TREMIE TYPE TO BE USED 0 AUGERS DHOSE 0 PIPE
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