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I <br /> SAN JOAOUIN <br /> Environmental Health Department <br /> i `7 I, --COUNTY- -- <br /> �,r, '•?� Greatness grows here, <br /> SITE MITIGATION WELL 8t BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. <br /> This application is made in compliance with San Joaquin County Development THIS,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job address 2651 South Airport Way citylstate/zip Stockton, CA 95206 Phone (510)_774-0064 <br /> Cross Street Ralph Avenue APN 169-120-0 2. <br /> Property owner Mendova Phone (510) 774-0064 <br /> Address 2651 South Airport Way chy/stateizip Stockton, CA 95206 <br /> C-57 Contractor Environmental Control Associates. LLC License# 695970 Phone (831) 662-8178 <br /> Address 3041 Twin Palms Drive Cltylstate2lp Aptos, CA 95003 <br /> ConsultanUSub-Contractor AE1 Consultants _License# Phone (408) 559-7600 <br /> Address 3880 South Bascom Avenue. Suite 109 -cityistatedzip San lose, CA 95124 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsile Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELDBORINO NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM GORING DEPTH 5.5 ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaporMaler) - ❑ HAMMERIDRIVFN DIP.OF BOREHOLE�❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASINGTHICKNESS TYPEOF CASING: ❑STEEL [I PVC ElOTHER <br /> M SOILBORING 4 ❑ PUSHPOIW(GPICR CONDUCTORCASING ❑Yes ❑Nb Bodng DIE Casing Ob: CuArg DepO: <br /> ❑ INJECTION ours,".ox. ❑ HAND AUGER GROUTSEALDEPTH TREMIE TYPETO BE USED: El AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ® OTHER Direct Push GROUT SEAL PUMPED? ®Yes [I No (Note:Maximum FMWI bPlh is 30 R) <br /> WELUSOIL BORING IDS SB-lthroush SB-4 GROUTSPECIFICATIONS PJeot+ G <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feel <br /> WELL IDS ❑PRESSURE GROUT To depth of_feetbelm surface <br /> GROUT SPECIFICATIONS. ❑EXPLOSIVES From_to_feel balm surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE ❑PIPE [I MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <br /> by certity that t am authorized to complete this application and that tha workwill be done in accordance wlth <br /> San Joaquin County Ordinanco Codes and Standards,and all other applicable California laws. <br /> Signed TillelCompany PXGq- . ,Y ( celcrr15A IAY�(C <br /> Print Name .)r �,atr�ge=sue Date�101?- <br /> PARTMENT UBE ONLY <br /> Application Accepted By:. Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA No in C/'� �a FA Address �f 65 S. 1 r`}��1'- FA# �p Z /,js PR# 0 f <br /> F. PE 2 50 WP ReNa red By "� 1 Work Plan Date q O ,Zo <br /> ❑C37 Au#xmzsJDntorOthu10 Sign Perme ❑Workers Comp ❑Workers CompWaker 08woedmiltPomdt ❑AmssAgreement ❑Lead AgencyAppmval ❑MFR <br /> COMMENT31 NDITIONS: s M ).� Pp!' .ti, �'{ yYl q,GLo MCA a SrC. <br /> �Y ( ilru♦_ S �►-ac� �P�► 'rP A0e ,%-'br0t1 <br /> wf► 6e bD <br /> tAIP TYPE PE I SCI FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit Z 10 ( $152 X 3 �� C C 4 (011 <br /> 00 <br /> 1868 E. Hazelton Avenue I Stockton, California 9 0/5r 1 T 209 468-34201 F 209 464-0138 1 www.sicehd.com <br /> EMD2aa10801-17 ( { 1 2�/ I ITe"9arn& 3D AppCptian <br />