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I SAN.,.] O A Q U I N Environmental Health Department I COU NTY - Gt'CQtnWSS Pot"'S here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2411OLirs Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madee inn compliance with San Joaquin County Development Title,Chapter 9-111/5.3,and the San Joaquin County Well Standards. Job Address R.� -q CL C,Al City/State/Zip C14 `! /°/Phone Cross Street 222 N&S APN 47(56- `/76 - O/D Property Owner' ,, 4 ka Phone Address D/00 City/State/Zip 95.215 C-57 Contractor , , r Licensed 9S-2 Y& Phone 91G 3761-/U y Address _�� -.., �� City/State/Zip /.)e,t 1 Syr-.-d.,�ie.,j41pCA V,5-691 Consultant/Sub-Contractor Licensell Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BoringslWells 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/Water) ❑ HAMMERiDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER 691rB®RtNG�' ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Ar or zo_ne/ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS [I HOSE ❑PIPE -A OTHER r�LC.LG (� OTHER GROUT SEAL PUMPED? ❑Yes [RNo (Nola:Maximum Freefat Depth is 30 FI) WELD SOIL BORING IDs S GROUT SPECIFICATIONS CSM civ a,.d a✓0.Z2�7— DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) I/WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feel below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet COMMENTS: �' �' yl hereby certi -t at i yn authorized to complete this appliCCaation and that the work will be done In accordance with Sa Jo qui County Ordinance Codes and Standards,and all other applicable Callfornla laws. Signed Title/Company 0652-p f. llzzce �Ku�i l tr s.scrr�a r Print Name kt .4 r/J. 4 Dale DEPARTM NT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Faclllt /Site Inf rma to s FA Name C ! (� FAAddress d� dlej ��" �j/ !c? FA# �) PR# FA PE WP Reviewed By Work Plan Dale Ift C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement []Lead Agency Approval MFR COMMENTS/CONDITIONS: Cf/ 1 � •�2 'f � T'�' G7 (fig WP TYPE PE SC FEE INFO AMT REMITTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit 3 $152 x (. 7 " I LC-1 --5' -', 1h'Z/z) un-F i rlyk A � bf 3�®S � - �12P"1' 8 1868 E. Hazelton Avenue I Stockton, nia yb[Ub 1 T 209 468-3420 1 F ZU1J 4u4-u i 38 I www.sjgov.org/elid EHD 20.01 06.20.21 Site Mitigation Wall Permit Application