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pip, S AW]a A Q U I N Environmental Health Department —00fUNTY----...... 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 wrck m City/State/Zip W Phone Cross Street omk T APN Property Owner* &WAS-1*11 Phone ZA w3 Address City/S telZip C-57Contractor V % License# Phone �OSb32R�8�S� Address 221 S.P2 W Im rLieCity/StatelZip tt0j3V3 Consuftant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note, Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vaporfwater) ❑ HAMMERIDRIVFN 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(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ €NJFCTiON W(irr S parue.Om ❑ HAND At1GER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE it PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Ma)umum Freefall Depth is 30 Ft) WELL!SOIL BORING IDs GROUT SPECIFICATIDNS DESTRUCTION WORK TO BE PERFORMER: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED OVER-BORE DIAMETER of 1l__inches to depth ofaAM feet WELL IDs .moo ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED UUGRS_`❑yH.OSE ❑PIPE ��l __tt ❑MUSHROOM CAP 1 `❑3 feet below surface or feet below surface if>3 feet COMMENTS: SSV Q-c q VAd utVa 1-4 W W JA 40 X t Or I—LO W�tV $o 4s' 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- Signed Title/Company Print Name 7 � 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# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Acoess 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 J T 209 468-3420 1 F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application