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•.i <br /> <` S A N:��J O AQ U IN Environmental Health Department <br /> .•n: .r l <br /> `j -----COU NTY— <br /> '"-lLir:ryl�.+:v%' Greatness grows here. <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 /> 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 application Is made in compliance with San Joaquin County Developmpnt TEU Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address y 5�.Y1i, i~1 IDc)rn<06 S�� SI'�'�- ,c lSt t�Zi ST�c.J/-w >'n y p ��Z6 Phone <br /> Cross street f= P i n e_ �;� APN I f-,?- Sv-Z1 O--000 <br /> Property Owner' Mr, MjA Le. t-&- !1'CE,1fl�n ►2egj es-k4e I.,.,�SI;nLn� �1Y1� Phone (ti60 8(13 ltI(8 <br /> Address 3Z!1 3 Atc e-� Or City/Stete/Z(p <br /> C57Contractor Licanae# C••5l ! 833ti Phone i 57ZS- 5 y.3} <br /> Address 3�1s�l C t1\ln$ rnu _ City/Stateop C4 '14Pf6 <br /> ConsultanVSub-COntractorApL,w E,A,ji.-"e(h T��, License# 7t)(-,I Phone (Cj Q 6( 6 <br /> Address 4 2 i P ft S t%.fc,tUS y t Q City/Statetzip Ci61 c4 &yer Ca CjS 7C-) <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsMalls Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> *MONITORING 2 19 HOLLOW STEM BORING DEPTH ' N(BOLTEDTRAFFIC BOX ❑STOVEPIPE <br /> O EXTRACTION(VaporMater) ❑ HAMMERORIVEN OikOFBOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> O SOILVAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS!r,HLit7 TYPEOFCASING:❑STEEL OPVC O OTHER <br /> ❑SOIL BORING ❑ PUSH POINT(OPI CPT) CONDUCTOR CASING ❑Yes X No Boring Dla: Casing Dle: Casing Depth: <br /> ❑ INJECTION Wrswroe.ozu el 19 HANDAUGER GROUTSEALDEPTH 1 h,t TREMIE TYPE TO BE USED.JE AUGERS ❑HOSE ffPIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED?EQYes❑No (Note:MaMmumFreefel <br /> WELU SOIL BORING IDs MW-uLT/V`Lk)-.tom GROUT SPECIFICATIONS 9Hi5 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of Inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To deplli of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED AUGERS I]HOSE❑PIPE ❑MUSHROOM CAP O 3 feet below surface or feet below surface 1>3 aet <br /> COMMENTS: �) p�f v L l�W J INLW l Lot.H 1N2(�tC �?i�o �j, 5au jrt:r�l tsln S <br /> Ycerti that! authorizpdtacom tetq.'fh 's )icattonsitdtitatthewoffr..ytirill,;pe•,ilofte:ln,accordpncsy/ith.•`;;; <br /> ....ortif r .. .....�.,:..:..... .. ............:.P... .: :. .:. pp.... <br /> ?' ::r.Ban:Toaqutn'CaantyOrdinence Codes and Standards;'and all otherapplicehie'Caitfornia laws: <br /> Signed Title/Company ()ir t- u <br /> j Print Name rc,.--, Lc,Y+J W e.-4.e Date L <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issue • Z-3 Z 7 <br /> Grout Inspection By/Dates: - + 6113127 dT <br /> Destruction Inspection By/Dates: <br /> Facilt /Site Information <br /> FA Name ,� U (�l t l U K �' FA Address t L C7 v­ FA# 1040 -44 11 PR# 6,5 " <br /> FA PE WP Reviewed By Work Plan Date ej '1 Z 3 <br /> ❑C57 ❑G57 Auftrizadon for OBIw to Sign Permit ❑Workers Comp ❑Workers Comp Walver ❑Erraoachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSiCONDITIONS: t toL,0S �v1 rS LV�1 CoG�+/ 7i r'� <br /> UV S W <br /> JWPTYPIEJ PE I SC I FEE INFO JAMT REmiTrEDI CHECK# E RCV' B DATE WELL PERMIT# INVOICE# <br /> Parma -L°vl 3j(�$172x 2 zl� r� (il tL tZi its ,�jJ�'Gq�r <br /> 1868 E.Hazelton Avenue I Stockton, Californis 95205 1 T 209 468-34201 F 209 464-0138 f www.sjcehd.com <br /> EHO 2"108.01-2024 Site MItIgallon Well PermltAppilcallon <br /> V <br />