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oA4`'i`�•� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT •: 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sicehd.com 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 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 b 4-q %J vJ eky r' i-1 i i` -'s L` City/State/Zip Lr t , ilk Phone Cross Street G . J, 'k z- ( - v I` a a :1 4 -if H11J Y -2-t APN 0 �� 4- 1_6 0 Property Owner* 5,1-r C'. JP c P i- P V,J ) Phone -7 09-4-4L 3 Address I } O r N Lt Z e 14-D r�J A v R-- City/State/Zip S• fZ;� C t✓ +-1 ti -S q -Contractor C 13 - 1 r i t '41 C License# l; ;-') Phone(, I '- �` ? 1' Address -11-11 —C S(C ,, e- City/State/Zip go.*a,v f—oa if.4A I i i `J 14 0 r Consultant/Sub-Contractor Lic e# �7 v `3 Phone Address City/State/Zip 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 e t 1 uIy I t, - ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE uKEXTRACTION (VaparMater) ` ❑ HAMMER/DRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE I❑ MUD ROTARY CASING THICKNESS 6 i TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: 15k, ?> C' GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs GROUT SPECIFICATIONS I"X — IC> i!�rU_ DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE p c U2 L_ t CI djv t I I hereb, Signed {{ Print Name M t ('JG DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet County Ordinance Codes and 5 u) okd -I e r"" a- S S (� i am. )a,4fj,l/ alication and that the work will be done in accordance with andards, and all other applicable California laws. Title/Company C -0 i- f Date -3' (� DEPARTMENT USE ONLY Application Accepted By: Date Issued: ��I 31I,6 Grout Inspection By/Dates: 'P �'��. /�sre 6� � �6 Destruction Inspection By/Dates: Facility/Site Information PAVA... FA Name FA Address FA# PR# ' FA PE WP Reviewed By Work Plan Date ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agen y COMMENTS/CONDITIONS:j` ��; yC rjj ._ �S ts�,'G� Wit.{ 15/-4> H rh �OrY ,MIy SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 447/300 1j7 C lb .v AC /3/G S(Z66-75/10 Permit $130 x 8 EHD 29-016-23-2015 Site Mitigation Well Permit Application