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• 0 <br /> SAN JOAQUIN p <br /> Environmental Health Department <br /> —COUNTY <br /> iy�gr <br /> `\`c�orFoaxA`� Greatness grows hr-�, <br /> SITE MITIGATION WELL & 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 corrlpliance with San Joaquin County Development Title,Chapter 9-1115.3.and,the San Joaquin County Well Standards. <br /> Job Address ,L JyI� ,F��tf 1 CltylStatelziip 41( /04 07S-34hone <br /> Cross Street 1� IPI.�NfY`t Yl�' APN Z 7 3 59 0 <br /> Property Owner* �F� Phone '510 6 u3 l 'b <br /> Address City/statelzip <br /> C-57 Contractor ( l e[Ofe rf l ll`✓f License# 0106 ��9 9 Phone 53D 66/ 36Z <br /> Address 'Z 1 P'Icer [--JA- .�— City/statelZlp w20�I-k Pt'/CA%4 Ca1� p <br /> Consultant/Sub-Contractor ✓� hU r License# 1 �1 Phone <jO �LI.Y a5o <br /> [, <br /> Address I tl�Ll ` V--,14 141 k y—CC)O City/State/Zip f'},t' ��-1 GiT �pc( 6I q- <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BodngsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH jo-2,0p ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapaMater) ❑ HAMMEWDRIVEN OLA.OF BOREHOLE 2" ❑MULTIPLE CASINGS MULTFLEVEL WELL CASING DIA <br /> tp1�t SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC❑ OTHER <br /> �l SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Die: Casing Die: Casing Depth: <br /> [[[]]] <br /> INJECTION(Air warm Dionel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS;R HOSE [2 PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes No (Note:Maximum Freelall Depth is 30 Ft) <br /> WELD SOIL BORING IDs GROUT SPECIFICATIONS F'0AG r < <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELL IDs ❑PRESSUREGROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED Cl AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 Feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify tha4 am authorized to complete this application and that the work will be done In accordance with <br /> _ .,63n j- in Co� /�fnance Codes and Standards,and all other applicable California laws.` <br /> Signed / �/ �=�/ Title/Companyrx I'rT h a f.e L (h �trr YiZr <br /> Print Name r.,e�I L. f/or A '�h Date <br /> V <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: '. <br /> Facllit /Sita Information <br /> a ,x , . FA# �0 1 � PRq ) j,310FA Name K. W FAAddress Pty <br /> FA PE 21 5D WP Reviewed By Work Plan Date <br /> 0C57 CST AWwdragon laOlher to Sign PamB Workers Camp ❑Worker's Cane WaNa ❑Enc�marhmeniPamit ❑Access Agreement ❑Lead AgenlyAppraval MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# <br /> Permit 152 x <br /> ` t 1868 E. Hazelton Avenue I S�ttockton,California 9520/5 1 T 209>46y8-3420 1 Fc�209 464--0138 -1(,www.sjcehd.com � <br /> Y� a EHD] -0t-t��i� L Vs013425 L-/` Is/L 1'(�I Ji�D/OW rtnit Application <br />