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i I SAN �.JQA Environmental Health Department 14a —COUNTY— SITE OUNTYSITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours 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 made In compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address eO-r, Gt.Z4C 6,-Al City/State/Zip S��G�foN, 1?14 9.5`;2/°/Phone Cross Street C'os u m N�S �1 ri L� APN a 2 YD 006 Property Owner* ek k1n, z,)ad1r ko- -T,ves 4 LC Phone Address D/ ,t% CItylStatelZip Sk,%k, [tom 9S•2/9 C-57 Contractor ",//4_cg s License# 95-9 Yr: / Phone 9111,' Address3rj "�, �,� �� City/State/Zip CA 4,4G 9/ Consultant/Sub-Contractor License# Phone Address City/State/zIp CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells 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) ❑ HAMMERIDRNEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER OIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: INJECTION(Ak S ar a o n ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE OTHER d� �O ((2 OTHER�GROUT SEAL PUMPED? ❑Yes [RNo (Note:Maximum Freefail Depth is 30 FI) WELL]SOIL BORING IDs _1_3/ rrru�/� S 7 GROUT SPECIFICATIONS ee,"cyj a—'d c✓a 7 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) It WELLS TO BE DESTROYED ❑OVERBORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE Q PIPE ❑MUSHROOM CAP 0 3 feet below surface or feet below surface if>3 feet /1COMMENTS: Sem /: �� (, 00 /(.C.3-� , /�l�ltf ICA 1 hereby certify t "t 1�m a thorized to complete this applicaUon and that the work will be done In accordance with SaVJaqu C unty Ordinance Codes and Standards,and all other applicable California laws. ,c Signed _ Title/Company j! 6 /al ice Print Name , Date DEPARTMENT USE ONLY � Application Accepted By: LU Z Date Issued: L/ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information SaAFA Name I FA Address FAII 1R#FA PE -5-0WP Reviewed By Work Plan Dale C•57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: u � � pe t WP TYPE I PE SC22 FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Gl .3L5 1$152, 1r 5" 1 U � � -Tv,,.) �l K00 4 2 Zq G r�vl I 3SSUS —�Az00� 39 6 9 1868 E. Hazelton Avenue Stockton, California 95205 1 1 209 468-j-t,-u l r _ 9 www.sjgov.org/ehd EHD 20-01 OG-20-21 Site Mldgadon Woll Pormil Application