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SANS DAQUIN Environmental Health Department "' 1= COUNTY�t Creotness grows heri�. 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 andlor 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 `. CitylStatelZip .y Phone Cross Street Spa APN Oq 31 2�5•,� Property Owner* Vii I- 1 m L�u.rl+ _� m Phone �q 76 J�3. Address P ( pp__ CitylStatelZip v f A� o�yro C-57Contractor +t .�4 CtiLl C License# kOy Phone 16050 :W3 MID Address CitylStatelZip CTlsr !7040 R1 F15�� qt� 7 Cons ultaiub-Contractor License# Phone Address CitylStatelZip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELL180RING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapodWater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA © SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GiCPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION IAirsiri Ozone l ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [-]Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELIJ SOIL BORING Ds GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:CCHECK ALL THAT APPLY) #WELLS TO BE DESTROYED OVFR-BORE DIAMETER of_9L inches to depth ot214 feet WELL IDs PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TRFMIE TYPE TO BE USED I� AUGERS ❑HOSE [-IPIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Vim —o'L ve 1--A" 64W It, 9,V 4- F-Z"WAA Voi I hereby certify that I am authorized to complete this application and that the work will be done in accordance with %� San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. LL Signed �1 TitlelCompany 410"dfi.L GUM &A r1j Print Name LA Date DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit !Site Information FA Name FA Address FA# Pi FA PE WP Reviewed Hy 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 AM T REMITTED CHECK# Rli BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 t www.sjcehd.com EHD 20-01 OB-01-17 Site Mitigation Weil Permit Application