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SAN J O A Q U I N Environmental Health Department COUNTY , FO Greatness grows here , SITE MITIGATION WELL & BORING PERMIT APPLICATION NON - REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL ( 209 ) 953 -7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described . This application is made in compliance wit San Joaquin County Development Title , Chapter 9A 115 . 3 , and the San Joaquin County Well Standards . 'otl .a Avco (�AkL w: - VZ`c7� Job Address r', 1 1 �1-�� , FJ , �= A4� L�6=4� 1 � City/State/Zip &*4 � 37 Cross Street Z, G; 1ST, - 'L,�S APN Property Owner* -� JG � r`Z�✓ S- ( �-1�� C l—�1,C �--lV�5?'i—r(�y � : y (_ L, Phone4.101011 Address tvlU� t 1�c �. � <<r �ICy-��( � ' � - � City/State/Zip jt;�e -moo 4q L 9 C -57 Contractor1jEj L, l 4C� License# °2,`�j c ' Phoned Address llpq0 I lwl� t�C —>� h� City/State/Zip !� �� Consultant/Sub -Contractor . v License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED . * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits n 13o / 2 TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS "l ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH i.% BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE e2 .4 ` L ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS � -- - � TYPE OF CASING : ❑ STEEL `9PVC [3 OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes No Boring Dia : 2 ,A lL Casing Dia : k 2� Casing Depth : 7 ❑ INJECTION (Air Sparge, Ozone) ❑ HAND GROUT SEAL DEPTH y TREMIE TYPE TO BE USED : ❑ AUGERS HOSE ❑ PIPE OTHER �— OTHER : .� _ ��_ GROUT SEAL PUMPED? El Yes `� No ( Note : Maximum Freefall Depth is 30 Ft) ELL/ SOIL BORING IDs GROUT SPECIFICATIONS rF-�s—A� G�t�l– �ly -�"� 1 •'� DESTRUCTION WORK TO BE PERFORMED . DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE [:] PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if > 3 feet COMMEWTire ,! A'C'C ISE /a 64 -{z'a,,,- 1 14S �t . I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards , and all other applicable California laws . Signed W0000A Title/Company "PC7ht1 ;;, "C , 02 Z , it t Print Name ` Date `'j 1 f� A,7 t ]DEPARTMENT USE ONLY Application Accepted : Date Issued : pp p B Y Grout Inspection By/Dates : Avow O� : tAvf 308 • 26 Destruction Inspection By/Dates : FT /�S �jy' / Z� • ZY Facilit /Site Information FA Name FA Address �d � 0 r- 'fi FA# 60 76 *0:7 PR# jPRO54TID FA PE WP Reviewed By LO Work Plan DateV it / 'Z / ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permitil El Access sAAgreement ❑ Lead Agency Approval FR COMMENTS/CONDITIONS : � � MVI � , _ C1 STI o� ►� (� Z.® Q I� 111s alb 1Q j- in WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELDL PERMIT# INVOICE# Permit 3 $ 152 x 5 Z � � O hp � 1 00Z3q y r�/v` a �a 3 " R o D 9 1868 E . Hazelton Avenue Stockton , CalifOrnla 95205 T 20 4� 8 - 3420 F 20946t0138 WWW . s ov . o �/ehd 19 9 EHD 291w01 0 &281,,21 Site Mitigation Well Permit Application