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i <br /> _. <br /> . SAKtJOAQUIN Environmental Health Department <br /> COUNTY <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 CZ-it/E City/StatelZlp 5,����/�,7, G�/� %So2/o/Phone <br /> r <br /> Cross Street Z;C APN <br /> Property Owner* 4/LG Phone <br /> Address /6yj /V » (�A 9S.2/9 <br /> C-57 Contractor L�Jo Hatter -��/,/ SSauc7 r License# 91 YG /f ' Phone 996 3>aA y <br /> Address City/State/Zip A i, J,AGra.le.v CA VS-6`// <br /> Consultant/Sub-Contractor Licensell Phone <br /> Address City/State/Zip <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 THICKNESS 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 I 1 ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> AgtER ZO 09 OTHER:<, a, `AOUTSEAL PUMPED? ❑Yes [RNo (Note:Maximum Freefall Depth is 30 FI) <br /> WELU SOILBORING I s -S ,&S 4A t=4 A A :j73 GROUT SPECIFICATIONS 4,,..d u/cr <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHAT APPLY) <br /> I/WELLS TO BE DESTROYED ❑OVERBORE DIAMETER of inches to depth of feel <br /> WELL IDs ❑PRESSURE GROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: .Qe— COVh G-A Oit1/1(„ Z' r,Q rXV IJ�'rA <br /> 1 hereby <br /> reby certthat I am authorized to complete this application and that the work will be done in accordance with <br /> Sa Jo 1 ul_ County Ordinance Codes and Standards,and all other applicable California laws. ,c <br /> Signed Title/Company CL=CJ G, 1/aca —�c��I �l�s.Sorlc [e r <br /> Print Name , Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: I Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facillt /Site Infor M <br /> FA Name �S, ci �(f FAAdclress f � �c� FAIT tDC) , PRA <br /> FA PE WP Reviewed By V I 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 MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE I PE I SC FEE INFO AMT REmirrEDI CHECK#I RECV-D BY DATE pWELL PERMIT# INVOICE# <br /> Permit 24'� 3�3 $152 x r 'J , Z ��C � �3 �f�/I Q 0 4 `Z Z Q Z <br /> C i rnn to 3 S `� K 00 g39 ! $ <br /> 1868 E. f lazelton A nue StoCk alifornia 95205 09 468-3420 F 209 464-0138 T www.sjgov.org/ehd <br /> EHD 20.01 06.28-21 Site Miligalion Well Permit Application <br />