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S A N J O A Q U I N Environmental Health Department COUNTY ,, , Greatness grnr+s het e. 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 fora 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. C. 3;tmEk- grvb �1 ^� Job Address CT T y R1t kA- ^ OF-^ WA�f MAI/1 S}FltylState2ip STaZA S T Or,/ Phone o(pq'.3v{3 ^ 6SIS Cross Street( Aj'/)'Q£E} aND ,C- 3- APN F— ' Property Owner* CI TY aF 5'1 cSC.K'.1 BAj Phone T-E)C7— 937-$49 Address 4 RS nl, F t. Oo AA✓o S T'. City/State/Zip S T C'Q[ i a 9 51 cs a C-57 Contraccttor U/ N C ED �o INC-- License# I©\o 37 14�J Phone ZQC1 4 b7^ I o o'jQ Address (J � 7 5koi W AO Aj 0 citylStatelzip �pS 1 OC t.1 oN CA) �2)5 11 Consultant/Sub-Contractor A , �r �. • License# I y�Il`�Z \b S Phone ZOCf T 4 0 7^ 0 Q NO Address i53'7 ShAW AQAtD Cllyistalelzip aN Cff 952) S CONSTRUCTION WORK TO BE PERFORMED:*Note: Offslle BodngslWells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORINGDEPTH ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VapoiMater) ❑ HAMMERDRNEN DIA OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIN ❑ SOILVAPORPROSE ❑ MUOROTARY CASINGTHICKNESS TYPE OF CASING:❑STEEL❑PVC❑ OTHER ❑ SOILBORING ❑ PUSH PONT(GP/CPT) CONDUCTOR CASING OYes❑No failing Diz Casing D'u: Caft Depth: ❑ INJECTION(A:sosee.ozmel ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED:[I AUGERS❑HOSE❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? [I Yes[I No (Note:Matlmum Freefan Depth is 30 R) WELU SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: c Ec LL A P LY '�-�-� #WELLS TO BE DESTROYED OVER-BORE DIAMETER oI inches lodepthof s17w feet WELL IDSRES$URE GROUT To depth of feet below surface GROUT SPECIFICATIONS o "D £ ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED [I AUGERS ❑HOSE IPE [I MUSHROOM CAP ❑3feetbelowsudaceor feel beluwsudace if>3 feet COMMENTS: wAr�'plPir.i DA-1Fo os^ oy - Zoz-o I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San J aquln County Ordinance Codes and Standards,and all other applicable Californla laws. c P n Signed �enz,.. UeLLJ� TlllelCompany �F/Y i 0( L7 0 0 51]i Print Name - 11 M 4z 7 Date fr�.S—^ Q 4 z O e y PARTMENT USE ONLY Application Accepted By: Dale Issued: Grout Inspection By/Dates: t Esd Destruction Inspection By/Dates: Facllit ISlte Information FA Name �� Address D f n FA# 00 Z3fa' R# OS ��S FA PE L V P Reviewed By ork Plan Date ZALI 0b7 0G57Au1hpmaknkrWiuto SignPemkk ❑Workers Comp ❑WOrkes Comp Walru En�m+ma�cawrAPemdl ❑Aa Agreewntt, /❑'Lead AgeMApproval ❑MFR COMMEN SICONDITIONS: M WPTYPE • PE SC FEE INFO AMT REMITTED (CHECK# RECV-D BY DATE WELLPIERMI7T# INVOICE# Permit 1 702_ 3I $152x I ice' Z G jqt) s Q0 �ID T QT'7 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01•17 Sae M`NeeOo'=Wr�tAypkaDon S _