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SAN JOAL1LJIN Entuthlon ental Health Depairlono t <br /> CUlf I�l I Y <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 /> 4fs HOUTII AOVIaRlfze IVc flrr3 { ef( INrrofi F(H Ail r ,T ^ i�r 1 ;teTJITs <br /> Application Is hereby made to San Joaquin County for o permit to consnucl and/os install the work described. <br /> "This application Is made In compliance with San Joaquin County Development Title, Chapter 9.1115.31 and the San Joaquin County Wall Standards, <br /> Job Address 23569 South Santa Fe Rand CltylSlate2ip RIverbanklCA195367 Phone (209) 550.1 154 <br /> Cross Street Henry Road ApN 249.070.120 <br /> Property Owner` Munlr Obald Phone <br /> Address 2616 Acapulco Way Citylstaterllp ModestOTCAI95355 <br /> c-67 Contractor V&W Dillin9 Licensed 057 #720904 Phone <br /> Address 1133 Blackhurst Drive CltylSlate2ip GaIMCAY95632 <br /> Consultant/Sub-Contractor Condor Earth L(censetf PC 116795 Phone (209) 743-7743 <br /> Address 188 Frank West Circle, Suite I City/State2ip StocktonlCA185206 <br /> CONSTRUCTION WORK TO BE PERFORMED: 4Note: offsite BeringsNVolis Require Access Agreements or Encroachment Permits <br /> TYPE OFWEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING" ❑ HOLLOWSTEM BORINGDEPTH O BOLTED TRAFFIC BOX ❑ STOVE PIPE <br /> Cl EXTRACTION (VaFco'=ar) ❑ HAMIAER)DRIVEN DIA. OFBOREHOIE 01AULTIPLECASINME) MULTI-LEVELWELLCASINGDIA <br /> 0 SOILVAPOR PROBE 0 MUD ROTARY CASINGTHICKNESS TYPE OF CASING: 0STEEL aPVC 0 OTHER <br /> 0 SOIL BORea O PUSH POINT (GPJCPT) CONOWTORCASING D Y85 No Bruig Ols Casigg Dia: C9shg Berlin: <br /> O INJECTION (Arss.— o7:. 0 W40 AUGER GROUTSEALDEPTH TREAIIE TYPE TO DE USED. 0 AUGERS [I HOSE OHPE <br /> 0 OTHER 0 OTHER GROUT SEAL PUMPED? ElYes ❑ No (NotaMangum Freelal Depth is 30 n) <br /> WELV SOIL 9CRING IOs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED; DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> O WELLS TO BE DESTROYED 7 ❑ OVER BORE DIAMETER of _ inches to depth of _ fool <br /> WELL IDs SV4 SV,1 IAW-1 MW-2 MW-3 MW4. MW-6 ❑ PRESSURE GROUT To depth at _feet below surface <br /> GROUT SPECIFICATIONS Neal Cement ® EXPLOSIVES From 26 to40feelbehwsurface <br /> TREAIIE TYPE TO BE USED ❑ AUGERS E] HOSE QX PIPE ❑ MUSHROOMCAP 03 feet below sofacea feet belay) surface It >a feet <br /> COMMENTS: E7plocives wh be placed below the sanilery seal to dep h. SV-1 and SV-2wngbeovHd"Iedt0d h (6feethgs). <br /> lei r� � t , 1��► 13 S� f� <br /> [ hereby certify that 1 am authorized to complete tills application and that the work will he done In accordance with <br /> _ San Joacittip County Ordinance Codes and Standards, and all other <br /> applicable Californly laws. <br /> Signed TIUefCompany CrCJ A7PIP, / L:7? JL&(FW : Y f <br /> Print Name L (�(_ rm*A T �E Date ®// / L, <br /> EPA# MENT USE ONLY / ZG� <br /> Application Accepted By: Dote Issued: 1 <br /> 014 <br /> Grout Inspection BylDates: <br /> Destruction Inspection BylDat s• 1a, <br /> ✓ r <br /> Faclift lSite Information <br /> fANeme �(tAQ,�' fAAdNessLT✓ ✓ V l 5�A,f^4 FAO oo 5 ,� ( � PRO 6 Cl ✓f ' <br /> FA PE � 29 � WP ReViaead By .W Work Plan Dale <br /> j 0057 fAuthahatrallot 011rlo Sign Peard ❑ WrkHeG ry, aWokr'sco"WeNa ❑ Encroachment PHtnl ecass Agreeaant Lead A9mcy APPrwd MFR <br /> COMMENTSIC NDITIONS: <br /> WP TYPE PE I SC I FEE INFO AMT RENin-TED1 CHECIV REc\rD BY I DATE I WELL PERMIT# INVOICE# <br /> Panni( 'L 3 ' $152x �g ® Z"(jvJ 00 q Z ! 1p <br /> 1868 E. Hazelton Avenue I Studdon, Callfornia 95205 I T 209 465-342D + F 209 464-0138 1 YWiW.SJceha. coln <br /> EHn 29.01 ge.o 1-17 elle Mirgaann Wel None AFWOcaann <br />