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SAN.,.JOAQUIN Environmental Health Department <br />—COUNTY- <br />-3 <br />OUNTYJI C'Iill �';S ,�It!�'�, itis'. <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) 9537697 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 <br />inn compliance with San Joaquin County Development Title, Chapter 9-1115./3, and the San Joaquin County Well Standards. <br />Job Address 120-9 6' -ZZ Ct, Lczit/ a City/State/Zlp 5,����/�,7, C14 7So2/o/Phone <br />Cross Street o --n APN 666 -0-T-0- A30 -000 <br />Property Owner* Phone <br />Address D i6yj City/State/Zlp i /r e L r�» 95.219 <br />C-57 Contractor License# 91-9 `/G / /f �� Phone 2Z(, 37a,I-IV - <br />Address ,3r)—n �.,�� �� a� CitylStatelZip �iK �AGr�Me.v f.�. C -A 4 5`6 9/ <br />Consultant/Sub-Contractor <br />Address <br />Licensell <br />City/State/Zip <br />Phone <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells 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 (VaporlWaler) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICHNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION IMS a Ozone I1 <br />,,rr-�- ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS El HOSE ❑ PIPE <br />AgIER -Z[H OTHER:. AOUTSEAL PUMPED? ❑ Yos [RNo (Note: Maximum Freefall Depth is 30 Ft) <br />WELU SOILBORING I s S ,&S 4%&4te 3 GROUT SPECIFICATIONS 4,,1d wc+ <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 ❑ PIPE <br />COMMENTS: 3ZP— Oh <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of <br />❑ PRESSURE GROUT To depth of feel below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below <br />feet <br />I hereby <br />reby cert tnat I am autnonzea to complete nils appucauon ano inar rine worn wul oe crone m accoruance wrur <br />Sa Jo ' ul_ County Ordinance Codes and Standards, and all other applicable California laws. ,c <br />Signed Title/Company CL=CJ r <br />Print Name , Date 7 -/ � 2 <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />FacllltvlSite Information <br />FA Name <br />Ci <br />�S, cl F <br />FAAddress <br />l S <br />� �c� FAA OCA <br />PR# <br />FA PE <br />WP Reviewed By <br />I V <br />Work Plan Dale <br />C•57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Ap oval RrR <br />COMMENTSICONDITIONS: ^A <br />rw <br />WP TYPE <br />I PE <br />I SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />I RECV-D BY <br />I DATE <br />PERMIT# <br />INVOICE# <br />Permit <br />24'� <br />3�3 <br />$152x �- `J , <br />�C <br />13 <br />pWELL <br />�f�ll Q04 `ZZQZ <br />rev, to 3 S b o ,59 oo S39 6 g <br />'1868 E. Hazelton A nue Stock alifornia 95205 09 468-3420 F 209 464-0138 TT www.sjgov.org/ehd <br />EHD 20.01 06.28-21 Site Mllloalion Well Permit Application <br />