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S A N -.,J a A Q U IN Environmental Health Department COUNTY Greot.r;ess crows ber=- 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,,Aand the San Joaquin County Well Standards. Job Address Citylstaterzip 10Kt} Phone Cross Street APN Property Ownor* Z1 Phone 011 Address _ City/State0p Q %6c" C-57 Contractor '4. Y &'(v l V& License# k t m(A fps Phone 1(�51) 3z8 Ib Address ' �MAr S�. _ CitylState2ip - m, }' �1 Q t{2.8 ~~� Consultant/Sub-Contractor License# •� Phone Address City/StatefZip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringslWells 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(VaporMatw) ❑ HAMMERIDRWEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS Lj 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: ❑ INJECTION(ArSname.ozone/ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mabmum Freefall Depth is 30 Ft) WELLI SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLYE #WELLS TO BE DESTROYED 'OVER-BORE DIAMETER of _ inches to depth of��feet WELL lDs Sy a— ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS O +) ❑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: SV I 3 L-4`t WW�o 2%1 4 t—'fit 6A 4b +mil I hereby certify that E 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 C> -ii Title/Company P Print Name �.Qrrk ��C4l 4 _ Date 2- DEPARTMENT USE ONLY Application Accepted By: Date Issued.- Grout Inspection By/Dates: Destruction Inspection By/Dates: Faciiit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worlees Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMME=NTSICONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECWD BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue J Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 J www.sjcehd.com EHD 29-01 OMl-17 Site Mitigation Well Permit Application