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'W^ SAWJ 0 A 0 U I N Environmental Health Department <br /> COUNTY- <br /> Creatoess grows h rr:. <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 nG CitylStatelzip L-0& ,LK i Phone <br /> Cross Street { APry C)LV S I I <br /> Property Owner* ( G Phone Zfq ''S(21 b?AL <br /> Address NFLSek. stg CitylStatelZip L _ C� , 5-2-4.0— <br /> C-57Contractor li License# 104%490ts Phone 650 99n <br /> Address , CitylStatelZip (Fo4 odlD A6. PA, QL(?J 3 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringshVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> El MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapar.Mlater) ❑ HAMMERfDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA <br /> [ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP)CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparse,ozone} ❑ HAND AUGER GROUT SEAL DEPTH TREMI£TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPI ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL!SOIL BORING 10s GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHI CK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYE ❑OVER-BORE DIAMETER of IL inches to depth of21!- S&eet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS d ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED IWAUGERS ❑HOSE ❑PIPE ElMUSHROOM CAP [-1 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: Gli —I V^ li W.1'� 24 A 1 —4% 1 4S <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 C-1� TitlelCompany e <br /> Print Name f�xr� I�� Date Y�Q/1tt1� 'L <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection BylDates: <br /> Destruction Inspection By/Dates: <br /> Facilit ]Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑4ecess Agreement ❑Lead Agency Approval ❑MFR <br /> COMM ENTSICONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV I)BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 ( T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br /> EH©29-a1 08-01-17 Site Mitigation Well Permit Applicalion <br />