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1411 J n �.� 6F°�: � �� e �� t Health Department <br /> l'�l T <br /> For Wells and Borings Used for con `carafnanit Investigations and Rernediation <br /> NON -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � F `v' if3L1V' fikdVolll : � 1 '� 'wiTt �: IGi9Yes u tJ i .ler iY1 = i ; ti � : 1 ::: <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 Title , Chapter 9-1115 . 3 , and the San Joaquin County Well Standards . <br /> Job Address <br /> 23659 South Santa Fe Road Citylstate/Zip Riverbank/CA195367 Phone (209) 550- 1154 <br /> Cross Street Henry Road APN 249- 070 - 100 <br /> Property Owner= Jose Cano Jr . Phone <br /> Address Z616 Acapulco -Wray itylState /zip <br /> C -57 Contractor V&W Drilling License# C57 4720904 phone <br /> Address 1133 Blackhurst Drive City/5tatel2ip GalUCA195632 <br /> (209) 743-7743 <br /> Consultant /Sub -Contractor <br /> Condor Earth License# PG # 6795 phone <br /> Address 188 Frank West Circle , Suite I CitylState/2ip Stocl<ton1CA195206 <br /> CONST RUCTION WORK TO BE PERFORMED : ' Note : Offsite Borings /Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUFABER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ I,{ o,�) , ITGRI ,;z ❑ HOLLOW STE61 BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br /> ❑ EXTRACTION fJaccrrVdatef) ❑ HMNAEIVDRIVEN DIA OF BOREHOLE ❑ t.4ULTIPLE CASINGS ❑ MULTI • LEVEL ;'TELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ htUD ROTARY CASING THICKNESS TYPE OF CASING ❑ STEEL ❑ PJC ❑ OTHER <br /> ❑ SOIL SCRING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia Casing Da- Casing D &PIh <br /> ❑ (t4J=CTION (A_rSoa:ae , ozone/ ❑ ht4NDAUGER GROUT SEAL DEPTH iRE�41E TYPE TO BE USED ❑ AUG RS E:1 HOSE ❑ PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑ Yes ❑ No (Note Maxirnun Freefdl Depth is 30 FI) <br /> l'1EL�-- S^IL BCPING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORKTO BE PERFORMED : DESTRUC'T' ION METHOD : (CHECKALLTHAT APPLY' <br /> # WELLS TO BE DESTROYED 1 ❑ OVER- BORE DIAD, ETEP, o` inches to depth of feet <br /> VI) ELL IDs t.1'',N-7 F] PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS Neat Cement [j] EXPLOSIVES From 26 to 4L' feet below surface <br /> TREfv1iE TYPE TO BE USED E] AUGERS E] HOSE El PIPE ❑ MUSHROOM CAP ❑ 3 feet beton, surface cf fit behv; surfacer >3 feet <br /> COMMENTS : Explosives vsnll be placed below the sanitary seal to depth . <br /> I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br /> an Joaqu County Ordinance Codes and Standards , and all other applicable California laves , <br /> ✓<= _ � �— Title/Company (] ( r✓� - 1 <br /> Signed <br /> Print Name t�Q �.s't�Y _ Date <br /> EPARTMENT USE ONLY to /� �� oz( <br /> Application Accepted By: Date Issued : ` <br /> Grout Inspection By/ Dates : <br /> Destruction Inspection By/ Dates : ` � Z <br /> Facilit !Site Information // <br /> FA Name � r �A+1'�C . Qtrl AAddress ?j ✓ � � FA 0 z ,S3 � � PR# d 5�' � eJ�Z <br /> FA PE WP Revievyed By �� Work Plan Gate ✓/ f �Z / <br /> zg o til <br /> ❑ C•57 ❑ C•57 Aulhodzabon for OUtFs Io Sign Pentit [I Workers Camp E] Waka's Comp Waiver ❑ Encroachment Perrrit ( Access Agreement [;3m ead Agency ApprovalFR <br /> COMM ENTS/CONDITIONS: <br /> '�Sl /L <br /> IQSI�mk <br /> 1 ' <br /> VUP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV''D BY DATE WELL /PERMIT# INVOICE# <br /> ZL TZ <br /> Permit �q0 � � J $ 152 x �J t/ V ©V —! <br /> P1868 E . Hazelton Avenue stocklon , Gaii ornia 95205 T 209 468 - %j 4 F 209 464 - 013r; vmvvv. sjcehd . com <br /> Site Mitigation Well Permit AppLeation <br /> EHD 2M oa-a 1- 17 <br />