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UI SAN J o A Q U IN Environmental Health Department <br />Lr�j`I~ COUNTY <br />� 14ji.��r`t Greotoors Groves dere. <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 Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address vel a- Z461— /-6,..N&— City/State/Zip ir/���r�,�, CA 9.s -,;)/°/Phone <br />Cross Street Cos. U m n/ &-g A ri &,c APN a ZYD 006 <br />Property Owner* {k k1,, 44C Phone <br />Address D/k City/StatelZip 51rri� �Iy �. [' 95.2/9 <br />C-57 Contractor ",//&Cg a7z s License# 95-9 YG // Phone 9111,' 3;;61-/V39 <br />Address 3rj ",,�,� ��� City/State/Zip <br />Consultant/Sub-Contractor License# 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) ❑ HAMMERIDRNEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />OIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION (AGS ar a o n ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE <br />OTHER d� iti0 (2 OTHER�GROUT SEAL PUMPED? ❑ Yes [RNo (Note: Maximum Freefail Depth is 30 FI) <br />WELU SOIL BORING IDs 5 3/ rrrc,� /� S % GROUT SPECIFICATIONS ee," c,yj a. rd c✓a 7 <br />DESTRUCTION WORK TO BE PERFORMED: <br />It WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE El PIPE <br />COMMENTS: Sem /;_M <br />San <br />Signed <br />Print N <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVERBORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feel below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />O -Y1 (A✓ 00 L�ZZI�l 4.4,— r20 �SIdX <br />rized to complete this <br />Ordinance Codes and <br />3I1caUon and that the work will be done in accordance with <br />andards, and ail other applicable California laws. ,c <br />Title/Company CbCJ <br />Date Issued: ! ! C/ [ �� <br />FA Name <br />FA Address <br />/140 If e� <br />FAII <br />�[9 ` PR# <br />FA PE <br />q <br />WP Reviewed By <br />UWork <br />Plan Dale <br />C-57 ❑ C-57 Authorization for Other to Sign Permit <br />❑ Worker's Comp ❑ Workers Comp Waiver ❑ Encroachmenl Permit <br />❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: I <br />WP TYPE <br />I PESC22 <br />FEE INFO <br />AMT REMITTED CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />Gl f�� <br />l7 <br />$152 <br />6071f; /'BVI ,V' 1263SSLgj— ( - 5900 � 39 6 9 <br />1868 E. Hazelton Avenue r - <br />Stockton, California 95205 1 1 209 468-j-tu I r _ 9 WWW.SjgOV.org/ehd <br />EHD 20-01 OG -20-21 Site Mldgadon Woll Pormil Application <br />0 <br />