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9 <br /> SAN J O A Q U I N Environmental Health Department <br /> G ' ' <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 /> T�aPPkatlon le rnAida�M�wmpbnoe v�Nh Saion Is hereby mobn Joaquin Development Title,Chapter 9-1115.3,and the San te <br /> � ( (/ Joaqutn County Wel Standards <br /> Job Addr. _I z CC S. M w Citotawop I t P►i e c e CA Phone Z 9'2 3 S� <br /> Cross Street r C A APN TO-V 0,f <br /> Property Owns• 0 a cA-t. u.r..?/� (/,Lr yc�t�j Phone Z07-92Y- 36 7?S <br /> Address (7-00t S, !1 —' CitAbAwzlp ltl frca CA 7s33 6 <br /> C-57Conbvclor U u , :;.,eLlcan # 'i ®7.Cf Phone 707- <br /> -317r/'(3C0 <br /> Address SSO f�i J 4,,% Chtosta'sop , V,, CA #TVs 71 <br /> Conwlantfllub-Contractor el1AQ S T-AcL uoon"S _KPhan '(IS -t1(3 21r0 <br /> Addrees'So5 2-=.1_S1--, St✓c 30o S cttotat rnp Freu"trete <br /> CONSTRUCTION WORK TO BE PERFORMED:'Nolo Olfdte Bori gslwelle Require Access Agreerrats or Encroachment Permits <br /> TYPE OF WaIMORNO Ma= tNSTA1LATIDN TYPE <br /> $f MWTORW MUOW ATM eorwa DEM D eDLT>D TRAFFIC sm 047M PIPE <br /> ❑ exrRAcrtDN IVaporMtraq ❑ wuatERDpVEN DK OF eoREHOLE D MM7Pr.E CuwrA D"TF{EVEt we.L CAM <br /> DIA7 <br /> aIbAY❑ 90K.VR MAE <br /> aC t j YO TYPE OF cAsrac D STEEL 12 PVC❑omm <br /> ❑ e0L 90FA o ❑ RM PWIT pw CPO CDNDI1CFM CASINO ❑Yoe Cl No earn pc _ _CWV DY CMM Dmpk <br /> D etlecnoN wj=L*m l ❑ NAND AUGER GPM WAL DEM 2I Twim TYPE TD eE USED: [3 AUGERS[3wSE A PPE <br /> HE <br /> ❑OTR 1307wt-- GWff SEAL KAVEW Ya❑No P1W:Unier.FMW10*6la M FE <br /> WEll/epi e01MIG p GRCUT SPECT"TIONS A I d:E C R—&,-1 <br /> DESTRUCTION WORK TO BE PERFORMED: DEarsuanoN himoD:MHECKAL!TKATAPPLYI <br /> =WELLS TO BE DESTROYED ❑OVER-BORE DUIETER of 'rl iodoper of trot <br /> WELL IDs _❑PRESSURE GROUT To dept a belEelar enface <br /> GROUT SPECFICATIDNS ❑EXPLOSIVES Front to bM below aarba <br /> TRE1rE TYPE TO BE USED 0 ANGERS - HQSW0 0 MUSHROOM CAP ❑3 bet below erbaor,_heal below verba N>3 bet <br /> COMMENT'S: <br /> I <br /> I hereby cu" I am authorked to complete this application and that the work will be done in accordance with - - <br /> �j <br /> Joe County ordinance Cedes and Standards,and all other q <br /> plicebleCalitomla laws. <br /> Slgrrd T Iy 6 io M <br /> Prklt Mann. r>rL...Q (r �-(c L..ec. <br /> Data '71Z/ <br /> D;CAOTMENT USE ONLY <br /> Application Accepted ST. Date Issued: <br /> GmA hapeceon BWDM-: <br /> Destruction Inepecdon ByrDwr <br /> Facility;S1 9 Information - — <br /> FA Nelle ;.- tau►^'��V r ny vt� FAAddna tY 1�I S. �..+� R 9 FAI PR! Lx�4 2,0001 <br /> FA PE 2 ++S" J WP Rewered By t-.- TZ-pl-,D* —7 <br /> ❑0V (1 "Aatl War te oear b teys Pease O Wodw'a Caee ❑Wbrlrh Cww watrw D Ewactreww Paved D AwwArnow MiewAswq Aw aal <br /> COMMENTMONDITIONS: <br /> WP TYPE PE SC I FEE INFO JAMT REMtTTEDI CHECK!I RECV-D BY I_DATE WELL PERMITS INVOICES <br /> Permit <br /> 11388 E.Hazelton Avenue I Stockton,Califomia 952051 T 209 4M34201 F 209 484-0138 1 www.sjcehd.cclrn <br /> EMMM06-01.17 sMokidMwaaPown pkaboe <br /> wf ZAVo 51AIS2.�3 y11 tsc.: 6-c Go-111gel <br />