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SAN JOAQUIN <br /> COUNTY <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2/1, HOLIrs Advance Notice d For Ali Inspections <br /> CALL `_--/ --- . -_ For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct ~- '--ll'- '-'------ <br /> �mmoaon�oonvmcuun�wv a�nua� <br /> ".=^''="°".="=".~~."~.~.~~.~..~..~~...~~^.,~~.~~.~.Title,- Chapter9-1115.3. ' s. � <br /> -57 Contractor c Y( <br /> Licenseff 9-S Phone 91/6 3,%2-1V35j <br /> - - ---- <br /> Address City/State/Zip V,5-6ql <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 /> El MONITORING El HOLLOW STEM BORING DEPTH [I BOLTED TRAFFIC BOX El STOVE PIPE <br /> 0 EXTRACTION(Vapor/Waler) El HAMMERIDRIVEN DIA.OF BOREHOLE [-]MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA <br /> El I A ORPROBE El MUD ROTARY CASING TI IICKNESS TYPE OF CASING: I-]STEEL El PVC [I OTHER <br /> -�R CASING <br /> So <br /> 6IL'BO= I--] PUSH POINT(GPI CPT) CONDUCT 0 Yes El No Bo(ing Dia: Casing Dia:_Casing Dep1h: <br /> OLB <br /> EINJECTION(Alt S of a 0 0 El HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 0 PIPE <br /> -fL OTHER P M OTHER,<pficf ,,GROUT SEAL PUMPED? Ej Yes EgNo (Note:Maximum Ffeelall Depth is 30 FO <br /> MELLI SOIL BORING IDs S I jtA y-o,Ir,A S -I e-) GROUT SPECIFICATIONS <br />