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Job Address Address eent., \ SAN JOAQUIN Environmental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. City/State/Zip ' AC.olle...,‘ 0‘CP.,,Cy( , L A cAS 3S Phone Cross Street APN ?0-1 - (3 (4.°- WitiPs' 4 .7 Property Owner* Z ewiwi (0,064,1:4es - 3e-cc a.....o.^:4 phone cas -231 - Address CPI A I rlAdidtv• 0 0.%A1o.".1 s ,-k'l- 1-10 3 i ' City/State/Zip SO.n 3cse 1 6A qSIIS C-57 Contractor c),Qvi OK. Oa- --4 c-: License# 9010P-77 Phone IA- 30 - 01 • -Y6 Q-) Consultant/Sub-Contractor License# City/State/Zip IN b-ool La (\ti C' ii- ci SI 7 6 Address .)..J_.0 f\)--3-,-cs--1- 1- Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: 'Note: Of/site Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING 0 MONITORING lAt EXTRACTION (VaponWater) o SOIL VAPOR PROBE SOIL BORING Li irriEcTiorl (A, spyo. 0 OTHER WELL! SOIL BORING IDs NUMBER INSTALLATION TYPE CONSTRUCT! N SPECIFIC TIONS ....t. . 0 HOLLOW STEM BORING DEPTH es' ei h' 0 BOLTED TRAFFIC BOX ,c,x4r, 0 HAMMER/DRIVEN 0 MU_TIPLE CASINGS 0 MULTI-LEVEL WELL CASIP:G DIA DIA OF BOREH E 1-4% 0 STOVE Pi PE 0 MUD ROTARY CASING THICKNESS nt" e.. TYPE OF CASING' 0 STEEL 0 PVC 0 OTHER 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 YeS 0 No Soong Nix Casing D'ai 0 HAND AUGER GROUT SEAL DEPTH TREACE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE IkPih. 0 OTHER .1 GROUT SEAL PUMPED? 0 Yes 0 No (Note Mammum Freelall Depth is 30 Fl) GROUT SPECIFICATIONS s4 -5 4A-rgwit s - 7 e le' DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 0 OVER-BORE DIAMETER of inches to depth of feet El PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE ['PIPE 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feel COMMENTS: va. 4srl,l, c5 a,s i...r< (I j- 3 0 „...,,,,,As e,N, s .r.c e +,. 56 --t S42 --6 7. --1-e--ta i s--,,,-1., s-, I to' I hereby certify that I am authorized to complete this application and that the work will be done In accordance with .., an Joaquin County Ordinance Codes and Standards and all other applicable California laws. 0,1 Title/Company SA'AFP ,3 -Colo9:131- /E60 Iii. Wmi 1:Ilt4S-1" Dale U(' I 2.0 i8 Application Accepted By: 4/1kr-1.4g6C-TTAA..504,144k) Date Issued: H - k DEPARTMENT USE ONLY Grout Inspection By/Dates. Destruction Inspection By/Dates: Facility/Site information FA Name FA Address FA# FR0, ifs---4, FR# FA PE WP Reviewee By VVork Plan Date \ C-57 RC-57 Author-zahon for Other to Sign Permit 0 We/1(er s Comp 0 Worker s Comp Waiver 0 Encroxhment Perini 0 Acce,s Agreement 0 Lead Agency Approval 0 MFR COMMENTS/CONDMONS: c2-1)N— CO -IDS-6o i qc WP TYPE PE SC FEE INFO AMT REMITTEDj CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2_90 5- 313 $152x 3 List,. ob to eop .3qpi,a 1868 E. 1-lazelton Avenue Stockton. California 952051 T 209 468-342C F 209 464-0138 I www.sjcehd corn EHO 2901 08-01-17 Sae Mit,gabon Well Permit Application /2-01)-7 eel DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL Os (4, 2- wi.t1r AV to -Nei- Signed Print Na