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i S A N J O A Q U I N Environmental Health Department COUNTY RECEIVED,•w Grc�ntnr ss grows hire. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and RemediatiorbEC 0 6 2019 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described E R\ ITSta EWjC ES This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County e I tan ar Job Address S-1 S A 2-$,LT<D4- l A.j F City/State/Zip 5 Icx KTonJ�1 G� `V57C) Phone Cross Street SCOT- IE\£ APN y 7 C�MN� e f c e 5'r Property Owner* Q 0 r Phone 8 4 ] Address Q0 IN , FA AnKL-j I 3n � City/State/ZipT evQ-q r1 �— 33(o O P C-57Contractor SJA!�jP JD,21 ))L5 Cflr4P License# G QH (oI 1 Phone 9 ( �o -%03 13ss Address 33(a5 Fi -1- zt,ZCAl1- D QO C y/State/ZIp CnacNaRO C-A c) 57yQ ConsultanVSub-ContractorA8\j/it c,E D a8 FC 0 /`V'l 1 0 /1M license# Phone Z 1Z)Ci - y b 7- 1 O \o Address S k-N�J A oA D City/State/Zip S)OC V C P /,J 9 S -? )S CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN 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 Die: Casing Depth: ❑ INJECTION(Air Searge.Ozone) ❑ HAND AUGER 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) WELL/SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED SH A OVER-BORE DIAMETER of inches to depth of feet WELL IDs v wfI,b' M w-w 1 r'-' - 3 M"'( ' Z r �- t ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS PcA- L.4NO TyK -M [-I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS Da HOSE ® PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: SE F- w oP, K PIA,j PA V ZQ ll/ ze 20l � I hereby certify that I am authorized to complete this application and that the work will be done in accordance with nSan Jooaqui`n,,County Ordinance Codes and Standards, and all other applicable California laws. Signed �T<rmn e (�/ Jam— Title/Company PAC) 1,-wotnr,4 � • U Print Name 1 1 Nt O-T k y J . �1�)I/�2 Date_12- S Z o I c1 PARTMENT USE ONLY (} Application Accepted By: Date Issued: ZZ �� ( I Grout Inspection By/Dates: Destruction Inspection By/Dates: 7 L020 Facilit /Site Information FA Name N- ffk FAAddress � , aZ FA# 00 , :�>46 PR#FA PE - I WP Reviewed By _J, A 1 (WWork Plan Date ❑ C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Workers Comp Waiver [] Encroachment Permit ❑Access Agreement [ILead Agency Approval ❑ MFR COMMENTS/C DITIONS: 5 oo refw Wik l•.+a S t7e/4P 'WP TYPE PE SC I FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Zq0 313 $152x - -60 8 J V +2, 6 I IN403 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 OB-01-17 Site Mitigation Well Permit Ay0calion S►r?1��5� 1.5 2S