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ii, - SAN ,JQAQUIN Environmental Health Department —COUNTY---- Greatness nrcws �err.. 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 a%1 \J, n CLI<. 'awl City/State/Zip L,& c i� Phone Cross Street h &+Ftjt# APN o+3osao91 Property Owner" r G Phone Zoq 561 Q j Address F CitylStatelzip Lb C. C-57 Contractor 14thiir &%TV(&t License# o%4 E;d es—Phone l b Address 2A b 1- CitylState2ip fi�- & 115 (No3 Consultant(Sub-Contractor License# Phone Address CitylStatelzip CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells 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(VaporNVater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE El MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soame,Omnal ❑ HAND AUGER GROUT SEAL DEPTH TREMtE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL!SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL IHAT APPLY #WELLS TO BE DESTROYED -� VU [:1OVER•BORE DIAMETER of W inches to depth of Z=q6 feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: sVG� _6 4n uWW jo21 114411 Wd 10g3I ive-01 1'NII io�3i [�4 1 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 Calif rnia laws. Signed c� TitlelCompany W.- . �( Print Name Date DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection BylDates: Destruction Inspection By/Dates: Facilit ISite Information FA Name FA Addross FA# PR# FA PE WP Reviewed By Work Plan Date ❑Ca57 ❑Cb7 Authorization for Other to Sign Permit ❑Warkees 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 1 F 209 464-0138 1 www.sjcehd.com EHD 2"1 138-01-17 Site Mitigation Well Perini!Application