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S A WM A Q U I N Environmental Health Department <br />COUNTY. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />2411OLlrs 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 inn compliance with San Joaquin County Development Title, Chapter 9-111/5.3, and the San Joaquin County Well Standards. <br />Job Address It?._1aCLG4,:1,- C, Al City/State/Zip Phone <br />Cross Street APN 0 (5 `/76 <br />Property Owner' 41-a Phone <br />Address D/ ,t' City/State/Zip <br />C-57 Contractor (,,)Q,//&Ca - /�� <br />/, / d sSaGi 7 r Licenses/ 9s'7 Y& / Phone 9111, 3 261 -/Sl y <br />Address _��r ,��r,..� ��,e� City/State/Zip 1")e, CA V S`G 9/ <br />Cons ultantlSub-Contractor Licensel# Phone <br />Address City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMERiDRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />691rB®RtNG�' ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION(ntr or zo_ne / ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS [I HOSE ❑ PIPE <br />-A OTHER r eLC.LG i� OTHER r+�GROUT SEAL PUMPED? ❑ Yes [RNo (Note! Maximum Freefat Depth is 30 FI) <br />WELIJ SOIL BORING IDs 5 5 f y GROUT SPECIFICATIONS CGiyI CNi u ,.d wc+.ZK <br />L� ' <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />It WELLS TO BE DESTROYED ❑ OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs ❑ PRESSURE GROUT To depth of feel below surface <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feel below surface if >3 feet <br />COMMENTS: <br />yI hereby certi -t at I yn authorized to complete this application and that the work will be done In accordance with <br />SaJo qui County Ordinance Codes and Standards, and all other applicable Callfornla laws. <br />Signed Title/Company CU` -CJ 6 A.Tezera i� r <br />Print Name Dale <br />DEPARTM NT USE ONLY <br />Application Accepted By: Date Issued: w/ C��� <br />Grout Inspection By/Dates: cz <br />Destruction Inspection By/Dates: <br />Faclllt /Site Information j s <br />FA Name C <br />((� <br />FAAddress d <br />dlej- b'" 7// !L? FA# C� , PR# 1 ,5 , <br />FA PE <br />WP Reviewed By I <br />I Work Plan Dale <br />C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement []Lead Agency Approval MFR <br />COMMENTS/CONDITIONS:C�� <br />1 � �•�2 <br />'f <br />���� `� 4� <br />GT (fig <br />WP TYPE <br />I PE <br />I SC <br />I FEE INFO <br />JAMT REMITTED1 <br />CHECK#/ <br />I RECWD BY <br />I DATE I <br />WELL PERMIT# <br />INVOICE# <br />Permit[Zqo—�]313 <br />$152 x <br />(� <br />Ltd <br />�� <br />�'� Z) <br />vvt 00 <br />Calk i r►n A��2G�S G 6 g <br />1868 E. Hazelton Avenue I Stockton, nta yb[Ub T 209 468-3420 1 F ZU"J 404-u 138 1 www.sjgov.org/elid <br />EHD 20.01 06.20.21 Site Mitigation Well Permit Application <br />