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i Environmental Health Department SQ '.�QQQ cp�i"a Al COUNTY G(calness grov s here. SiTE 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 4 Al 0— City/State/Zip 5'1r)e C14 lS"o?/Phone Cross Street ('d c u m n/ES -X APN p 66 -OS-0- ow.SO'coU Property Owners 44C Phone Address 0 14ri City/State/Zip �5�c�,�r��-C� cis•21�i C-57 Contractor License# 9S`7 YG/ Phone 9/6 3 ZA-/y3cJ Address ;i,3-n,,r>/,_�, s/�r ��.�/ City/StatelZip kt d'�tt�,e.y�CA VS-6 ter/ ConsultanUSub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bortngs/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Waler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER —jA-S148ARING - ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia; Casing Dia: Casing Depth: ❑ INJECTION(Air Soamo.0zonal ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE —OTHER i,@ OTHE%6q .GROUT SEAL PUMPED? ❑Yes E'No (Note:Maximum Freefell Depth is 30 FI) ^ELU SOIL BORING IDs GROUT SPECIFICATIONS CCM r.v� a.ted u�cr DESTRUCTION W TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) It WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feel WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feel COMMENTS:Y19-e— '„ p �dYV� Qn ..! F�O(�i77Q�C� �� J1.G->Iy 1JIJh`ereby certi that I a authorized to complete this application and that the work will be do`ranee In accordance with Sa' Joa ui County Ordinance Codes and Standards,and off other applicable California taws. ,e Signed Title/Company CbCJ &k-//Lcr- 44,w 6 A.Snefta i r Print Name , Date A DEPAPTMENT USE ONLY n Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Inf rmati FA Name (' S "Vx&i FA Address sp„( D Mt FA# 10 0 Z to PR# S 4 FA PE If ZRWP Reviewed By Work Plan Dale —L-C- -57 [3C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp ver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval MFR COM ENTSiCOND�NS:�H j f1,, 11 WP TYPE PE I SC I FEE INFO , AMT REMITTED CHECK# RECV-D B DATE �pWELL PERMIT# INVOICE# Permit 2q� 3i?�$152 x r ✓ �` I CC V"� o 6 L,z?- � l ►2 31,x' /5-3 54Z 00 g39.(0 -1868 E, Hazelton Avenue Stockton, Ca I ornia 95205 209 468- 420 F 209 464-0138 1 www.sjgov.org/e1Td EHD 29-01 06-2a-21 Site Mitigation Well Permit Application