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II. �t"'`�` SAN JOAQUIN COUNTYik•.o I ;y' l � ENVIRONMENTAL HEALTH DEP,I%FTIOENT A W, J 1868 Hazeiton Avenue, Stockton, CA tlr.i/20::;-6232 'I Telephone: (209) 46$-3420 Fax: (209) ,368-3433 ,'/cb. www.sicehd.corTT SITE MITIGATION WELL & BORING PEFAII,r APPLICATION I For Wells and Borings Used for Contaminant Invesl gi&Dns and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR:=N CATE ISSUED Application is hereby made to San Joaquin County for a permit to constru:I a 1d. 2r install the work described. This application is made in compliance with San Joaquin County Development-Fitle,Chapter : 1.11i 3,and the San Joaquin County Well Standards. Job Address 16551 Chrisaryhar'Nay(iA5-2 City/State/Zip Lalhrz. CA952:6 Phone Cross Street -.11eway APN im."o-33 �i Property Owner" Rou Cates LLC.a Caft nia LmW habilay company (Co.N-.Yt Troy Eslacm Phone m6)379-3son L•.,f,i1,,�11 1,°'.iI!('' T LP ..--- Address 0515 Elder Creek Road J I 61 V,. # 11"-S' CltylStatelZlp saaa,lmc CA i582B C-57 Contractor AllwellAGandonmonl �1 92&1Z License# 848359 _ Phone Is1e13s3-939s Address 1369 Ftzgarakr Read CitylStatelzip Rand :or lore CA 93742 Con sultantlSub-Contractor Hy—Fows.lnc License# T Phone (smi 75g-mm Address 2927 spaflurd Slreel CilylStatelZip Darts, CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Accet,: Agroements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICA"IONS 0 MONITORING 2 ❑a HOLLOW STEM BORING DEPTH 31 � ❑BOL- _7 1 RAF FIC BOX ©STOVE PIPE ❑ EXTRACTION(VapaifWaler) ❑ HAMMERIDRIVEN DIA,OF BOREHOLE 10 ❑MUL-'I'LE CO,VNGS❑NILILTI-LEVEL WELL CASING OIA 4- ❑ SOIL VAPOR PROBE Cl MUD ROTARY CASING THICKNESS TYPE OF i A:ING ❑STEEL 0 PVC ❑ OTHER ❑ SOIL 80RING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING []Yes ❑r No 8cring Dc1 __ Casing Oia Casing Depth: ❑ INJECTION lAr 5parge,o7onet ❑ HAND AUGER GROUT SEAL DEPTH ton TREMIE' r 5E TC 3E USED ©AUGERS ❑HOSE Cl PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes g No (Note:Ma-i nut i F-:efalf Depth is 30 Ft) WELL/ BORING IDS KMw-I(l.KMW-ll GROUT SPECIFICATIONS near aone nitay sea'-'aI addilions12 n benlonita lran.M:-ses 1;KI w sanitary seal DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOI I_CI:ECK ALL THAT APPLY) #WELLS TO BE DESTROYED I 9 OVER-EORF D I±MI:TI:R of 05 inches to depth of ,1 feet WELL IDS KMw-3 ❑PRESSURE GROUT T- !eI 1h of feet below surface GROUT SPECIFICATIONS real comem ❑EXPLOSIVES F ;n —•_to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE 9 PIPE ❑MUSHRDOM CAP [: 31 ael)elow surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that thn w;rG will be done in accordance with San n Ordinance Codes and Standards,and all otho•app icable California laws. Signed y'J TitlelCompany All wall ..a, nn, ,It Pri ame S C� Date— --, DEPARTMENT USE ONLY Application Accepted By: tale I:;stied: Grout Inspection By/Dates: Destruction Inspection By/Dates: Pacllit ISite Information FA Name FA Address EF A#. PR# FA PE WP Reviewed By I Work Plan Date ❑C57 ❑C-57 Autharizalion for Olrer to Sign Permit ❑Warker's Camp ❑Worker's Camp Waiver ❑Encrcachmeli 3e1 mil ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTSICONDITIONS: — SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RE'CV'D BY 1)�TI: SERVICE I/ RE�QUEST# INVOICE# Work Plan 2 Qy 2� yG j y0 �0� C.g N( i� _l _ SR 007• /7 60 Permit � v l t� $130 x 2- r6D y,; cjvnZ /`-"/,' 5-ie 0 07 3 7 C 1 '9Vv g C/Vr i� I'lf,10- 5'j2 00 73 7 Z E:HD 29-01 6-23.2015 I