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SAN JCA !J <br />Q IN <br />Environrr'ental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />i� CALL (209) 953=7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This appli��vj�� ad�eir�nmplaance vyi#h San Joa uin Coun n Joaquin County Well Standards. <br />Job Address <br />Cross Street �,��•r�.�y,,� � f � CZE APN <br />�^A�ddress ���,��.0-IMiyts O � a�0"11 S-�,� r��tJ _ CitylState/Zip , <br />�� �Z7 Contractor _ <br />Address �� c' I <br />License# <br />City/State/Zip�,�_ �.,�.�.b{-�•_.�._-r.� , Gly <br />Consultant/Sub-Contractor }_l- � �., License# <br />Address <br />City/State/Zip <br />Phone <br />BE PERFORMED: *Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits <br />TY E OF WELL/BORING NUMQER INSTALLATION TYPE CONSTRUCTION SPEI <br />MONITORING �� '1N. A �HOLLOW STEM BORING DEPTH - <br />❑ EXTRACTION {Vapor/Water ❑ HAMMERlDRIVEN DIA. OF BOREHOLE _ <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS � <br />❑ SOIL BORING ❑ PUSH POINT (GP/CPT) CONDUCTOR CASING <br />❑INJECTION (AirSoarae.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH <br />❑ OTHER ❑ OT R: GROUT SEAL PUMPED? <br />WELL! SOIL BORING IDs M , \,� , -� GROUT SPECIFICATIONS <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS_ <br />TREMIE TYPE TO BE USED <br />COMMENTS: �CC��C <br />Signed <br />Print Name S <br />AUGERS ❑HOSE <br />I hereby certify that I <br />San Joaau <br />Application Accepted By: _ <br />Grout Inspection BylDates: <br />Destruction Inspection By/Dates: <br />S <br />1868 E. Hazelton Avenue � <br />EHD 29-01 06-28-21 <br />�rri�M i ivna�, <br />�� �'�OLTED TRAFFIC BOX STOVE PIPE <br />r'� �` ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />= �j � TYPE OF CASING: ❑ STEEL �'VC ❑OTHER <br />❑Yes No Boring Dia: C�Casing Dia: ��t� Casing Depth: 3 ' �t <br />� � {�(q�TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br />❑ Yes No (Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION METHOD' (CHECK ALL THAT APPLY <br />❑ OVER -BORE DIAMETER of inches to depth of� <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP ❑//3 feet below surface or feet beio <br />authorized to complete this application and that the work will be done in accordance with <br />ou� Ordinance Codes and Standards, and all other applicable California laws. <br />Stockton, California 95205 � <br />Title/Comps <br />Date <br />feet <br />if >3 feet <br />Date Issued: I / `Z� �� <br />209 468-3420 � <br />0138 � www.sjgov.org/ehd <br />Sift? Mitinatinn IA/cll perw.;� n...,u,...�;.,_ <br />