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SAN : 0AQUIN Environmental Health Department —COUNTY— Greatness grows here. 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 end/or Install the work described. This application is made in compliance With San Joaquin County Developmant Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. 1✓aRA14T51: ST, b Il Job Address c:�-ry RrL,h�'^OF' " wANl 1•.AvACSI city/State2lp 5Tcc'1 :T'z JC 1 Phone a011 ^ 3a3 -• (oS)S Cross Street LAFAY9T1£ E L4vAtL $•t— APN Property Owner` C•i i 5'T r- - Phone Sl0CI -937- $44N1 Address WtS N. rL AOQA0a S—f. City/Statelzip TQuk(Torj cAr99 ao-, C-57 Contractor Aa%,i4ACFD GEn / Inc , License# ID-%S7 65 PhonaY.Uy^ "Ib-)-)Q b Address as j S•hA wA� ROAD city/Statelzip • -f 9 t,K T c a on/ H 5S' /S Consultant/Sub-Contractor AG G 1- License# 10\0 3 7 b S Phone 0 \0 Address 33"2 Sti/jy gicAp City/State/Zip S-rz( KTory CA 9Sa)S CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsile Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATIONTYPE CONSTRUCT IONSPECIFICATIONS ❑ MONITORING ❑ 14OLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapwWaler) ❑ RARMERA)FIR N DIA OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [3 PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Bourg Die: Csskg tie: C"Depth: ❑ INJECTIONNSms.oearl ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETO BE USED: ❑AUGERS ❑HOSE ElPIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No Mote:Madmen Frodd Depth Is30 Fit WELD SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION'WORK TO BE PERFORMED: �DESTRUCTION METHOD:(CHECK ALL THATAPPLY) I - #WELLS TO BE DESTROYED I p�O•VER-BORE DIAMETERof S of-I Inches to depth pg feet WELLIDs ' PRESSURE GROUr To depth of feet below surfce a GROUT SPECIFICATIONS O- C ❑NO £ ❑EXPLOSIVES From_to_feel below surface TREMIETYPETO BE USED []AUGERSv❑HOS PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel belowsudaw U>3 feel COMMENTS: wOTT. N'j D.4\f<a �0510V f ZO Z-0 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 --�74aasmdw,4 f./'. W-RJJ4i Title/Company .SE.`"Ot tc 'Eol O5t " Print Name— I ) MO V CV 014 Dale O S^ Ch\) - 20 Zn DEPARTMENT USE ONLY Application Accepted By: Date Issued: 5 Grout Inspection By/Dates: Destruction Inspection By/Dates: acilll /Site Information FANsme kl FAAddress (1 0 a ill FA# 00 Z3g,>S' PR# 05-Y FA PE Z�6 D P Reviewed By ork Plan Dale s/Gf 2 n 7 ❑C47AWtoraation I"Olherto Sign Pent ❑Wadrefs Came ❑Woikees Comp Waiver ❑Enaoadiment Peemit D❑AccessAgteemera ❑LeadAgensyAWMI ❑MFR COM NTS/CONDITIONS: Itkwtl� ✓�SJb /a°Pjr,f LO Tit ` r-' 4A U.�' WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# IRECV'DBYI DATE WELL PERMITT#.p INVOICE# Permit I VOL 13 (3 s152x ( / ,r�2! � 1 1868 E. Hazelton Avenue I Stockton, California 952 5—IT 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com END 29-0108-01.17 site Mitigatbn Wes PemR Appi tk,n