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�eQm fib- [ SN QU Environmental Health Department - COUNTY recnes r Gt Q C24`d.5 here. 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. Job Address QRyy� �� _City/State/Zip L_ Phone Cross Street � {� -R APN C)+3p j Property Owner" Phone rod,U7 OC3� Address r City/State/Zip IZ& C6qo C-57Contractor r� 1- J i Z License# I Fhone (�;D �yo Rrb Address _Sit Nii &I[ � City/State/Zip f-_Ajj. pF�p qii ConsultantlSub-Contractor License# Phone Address City/StateRi p CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor, Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING; ❑STEEL ❑PVC ❑ OTHER [-I SO]L BORING ❑ PUSH POINT(GP7 CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparue,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE l7f PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nate,Maximum Freetall Depth is 36 Ft) WELIJ SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELI°Tn RE DESTROYED ✓ J i OVER-BORE DIAMETER of inches to deplh of�ieei WELL, t i r — ❑PRESSURE GROUT To depth of feet below surface GROUT SPEt;IFICAT NS pe ft ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED 1KAUGERS ❑HOSF ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS:Vrtiw.ot trw��tly.. -�uW � I-2n �o # i L#lam-Iota e� l-z'#Watkr SV E-e2 v%t 4-411 wXt to xti' 4 i-44 Wig f-6 CIS# V!� _7X 10 g�#4 t-1,( "�IFS# I hereby certify that I am authorized to complete this app ication and that the work will be done in accordance with �% San Joaquin County Ordinance Codes and Standards,and all other applicable Californ�i ylaws. {�_ Signed C Title/Company �n&JV t�Q l'I�C�fr &jZVjfP� LLC Print Name Date ImA*r—�_ DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit !Site Information FA Name FA Address FA-4 PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTSICONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 j F 209 464-0138 1 www.sjcehd.com EHD 28-01 08-01-17 Site Mitigation Well Permit Application