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°f -11I SAN JO1�C�CJIN [)0.,p �r arnent COUNTY �''tr,rr-nR�'�5^ Vr'c:atncss ifrur; (1L'r'C. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2/1, HOLO •s Advance Notice ROgLlil'ed For !'SII Inspections CALL (2.09) 9537697 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 with San Joaquin County Development Title, Chapter 9-1115,3, and the San Joaquin County Well Standards. Job Address A?84 CL City/State/Zip 5'>l7cL ��nr CT S' /°L Phone Cross Street ('Os u r� n/ &S t\ w 1h& APN O ( K - p-�-O - .266 - 000 PropertyOwner* C�cr�%w /Jesi�c� cL J vr�.i�irlc.v>ls /.LC— Phone 0 Address Oi ii City/StatelZip 0j 9S2/cy C-57 ContractorGcJcLl�ac� - �. J�i SSaG�r�/o r Licenseff 5,5-7 y6 / Phone 1,;1/6 372 -1V35� Address City/State/Zip Jc5 �AGrc7 �e.�rCA �i 5`G �r� Consultant/Sub-Contractor Address License# City/State/Zip Phone CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Waler) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA El I So APOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: I-] STEEL El PVC [I OTHER @It BDR1A�' ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑Yes ❑ No Baring Dia: Casing Dia: Casing Deplh: INJECTION (Mr S ar e o cne ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE OTHER P M OTHER jai r"GROUT SEAL PUMPED? ❑ Yes E#No (Note: Maximum Freefall Depth is 30 Fl) ELLI SOIL BORING IDs S I jtAy-o,/,A s -I e-) GROUT SPECIFICATIONS �'p�yrrayF c>n.d lila DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED []AUGERS ❑ HOSE ❑ PIPE COMMENTS: Cis y� fan Signed_ Print Name Application Accepted By: Grout Inspection By/Dates-77 Destruction Inspection By/Dates: Facllity/Site Information DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of_ [:]PRESSURE GROUT To depth of feel below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 reel below surface or feet bele feet surface If >3 feet ilrev See "CoL rte.- D CCC f -LI 0�)— L-5 ell, (y - 4.!r t t Lam authorized to complete this application and that the work will be dt5nL, in accordance with v , k- inin County Ordinance Codes and Standards, and all other applicable California laws. A -A V Title/Company CSU ace - u a V Dale :NT USE ONLY (q Q Dale Issued: FA Name Uyl t-j`it,t �� C rtit FA Address �jt;�{r,t,'fa•�i(/l �� FA8 „ C , t , �I PRf1 j WP Reviewed By �tf1,! Work Plan Dale FA PE C-57 ❑ C-57 AulhAzallon for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachmenl Permit ❑ Access Agreement ❑ Lead Agency Approval WR COM ENTSICONDITIONS: t� 6,0� e) �-_ —atl 1 � WP TYPE I PE I SC j FEE INFO JAMT REMITTED1 CHECK# I RECV'D� BY I DATE/ WELL PERMIT11 INVOICEff Pormit I Fq6� l� $152 x / . Oar �V ! 7 / w V % 1+ z7sq op-k;rM 0 I�!-4 SIZ0093q 6 8 '1868 E. Hazelton Avenue Stockton, ali orll 5 05 T 209 468-3420 1 F 209 464-0138 1 www.sjUov.cr0/ehc1 EHD 20-01 00.20-21 Site Mllipation Well Permit Application