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10 0 <br /> SAN JOAQUIN COUNTY RE4 N ® <br /> Tr ENVIRONMENTAL HEALTH DEPARTMENT APR" 19 2017 <br /> 1868 Hazelton Avenue, Stockton,CA 95205.6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com ENVIRONMENTAL HEALTH <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION PERMIT/SERVICES <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDAOLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applimtton Is hereby made to San Joaquin County for a permit to crosbW And/or Install the work dewibed, <br /> True eppl callm Is made In Compliance with San Joaquin County Derval pmenl Mile.Chapter 9-11153.and de San Joaquin County Well Standards <br /> Job Address -6076- 909 ,o B/4 y_ Q�. _ _.. _._ CHylstatomp rJ�kbzq 9,5ZO Phone Zo 9 -/O0C <br /> Crass sM.ee W�sfi `/a APN 06605 oS1Z"-Y <br /> Propertyt3wnee __ . _ Now-rd We,n Phone <br /> Address _ -2 V1. _TP.o - cllyrstatemp pa/a< UIidosC_Qo27' <br /> C-STcontraetw el 4 of, /A ajaL�21, T-Ir- Lt.. # Phone Sts 1 _'8oc <br /> Addnaa9So_� Qd. _-_- _ --- cltytsmlempl!6rl,-ra. CA 945-5.3 <br /> ConsullanUSub-Conbaclar Pes F,,,,,mon Y"+Cn'hn.�_�']GLh:ense✓t Phone I r6 -/(a00 <br /> Address 7665 9CJW,e ri- Rl✓r{ j if _Z__ cit0st■lemPAl.,L� 9Y9Y5 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note Offsite BodngwWeas Reguim Arres•.s ADmemenlso Encroachment POONIS <br /> TYPEOFY/ELtlBORINO !UMBER INSTAUAIIWN TYPE CONSTRUCTION SpEC"T1011S <br /> 0 MO MRNG 0 HOUDYISMU W"GOEPTH 1=7 q' 11�7•n 0901.1E01MFFlC aa+1 STOVE PPE <br /> ❑ExRUGTXIHiYAoaM1Yaal _01wiAERMM DKOPeOROW 2.. 0MULMECA31=01Aa.TUEvanELLCASH10r <br /> 0 SMVAPORPROeE 0 wo ROTARY r,N CAsew nlCMESS - i TYPEOF CASNG [3 WEE.0PVC 0 onmR le" - 4raY•2 <br /> $sotaORNG =0( PUSH PONTIGPfCPn CM UCTORCMIa Cl Y"RKw Haegllc CANDW Cb.y y,-.Pk <br /> r3 IrtiECVWwSoa.mml _0 iIWDAU B GRmrtsEALDEPTH riTYRE To BEUSED OAtasnt ONow 13 PIPE G <br /> 0 ONO wRNcor Cs OTIMLD- w`_ GwSEALft PM? 13Yw/Ota pwcu. F,widt?aPualSTq <br /> l root Nl ec/u <br /> .'f..m k+c f.uny_w• li�Qf a, less✓.c .r ne .fed <br /> T� <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:10ELH ALL THAT A= <br /> a WEULS TO BE DESTROYED IS ❑OVER.BOR£ OUAETERd_Yr7wbMpN ol_ket <br /> WELL Ds ✓.,!<naw" 29PRESSURE GROUT To deplb al rv��S kat hebr surbm <br /> GROUTSPECOCA:IMS T :� ,.�e - ..,n l7 E%PL0.51VE5 Fnm_k_feel OebwsWam <br /> TREMIETYPETOBEUSED AUGERS HOSE PIPE MUSHROOM CAP 3kdaelowsrfamar h:alDeWa aaface Br3leN <br /> COMMENTS: C-m�f �1'll �h,e,:-��L 1 1 r'ct'k J3 f?'e55JrC- w, ll hG ,n'1*u d✓ce-4 <br /> 14 ee'de c{ <br /> 1 hereby eartify that I em aulhorlud to complete this appilea0m and That the work will be done In accordance with <br /> San Joaquin ty ordinance Codes and ttandatda,and all other applicable California laws. <br /> Signed rnleGempanr�encr ShrCF F �fS C-✓.�bnek <br /> PrIMName .__ ✓�___ __ Dale / <br /> DEPARTMENT USE ONLY <br /> APpAcellon InspeA=ection <br /> Eyf(ed Br. Date Issued �/ <br /> Grout Inspectlon BylDaln: � <br /> DesWction Inspection SylOolaa <br /> to Infoanallon <br /> FA NaM / FAAddnrss -5` •' FAN L)L` V 1Z_ PRI <br /> FA PE � :,..• YVP MDae . , ./.6RMeS7 <br /> OC-57 DCHlAaTnlnknlaCthKwS 1Pew UWaia'rOme Owww,CawW&Im DEwroawNPemT IT�'AmrAAPswwe O .MAa�glAtpwd <br /> OMMENTSICONDITIONS: <br /> SR TYPE I PIE I SIC I FEE INFO JAMT REM CHECK/I RECV'D BY DA SERVICE REQUEM I INVOICEI <br /> Permit 138a -> / - -64 .1 i—1 c,77Z.60 <br /> END sse110-26.201s Site Mitigation Well Permit Appk4tlon <br />