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SAN WOUIN Environmental Health Department —COUNTY SITE MITIGATION WELL & OO XQ PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections qp Z400 955 �) 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 lffiSi L. wgd A Clty/StateeIZip CJr Phone Cross Street r {� k; APN Iz/ Property Owner' SGu G/,L i i11G1. Phone Address CltylStatelZip C �rr,, C-57 Contractor 1 , f- �l k -t License# t Phone 53ag -3rX D Address 720 /y �f S{: a:y G , CltylStatelZip 67 D pp�� LLtp, Consullantifluub�-Contractor/� License# 'rI �iTl Phoone 1V&- D /'y�Zq Address -/VV GUBSL 1 h1d S Cily/State/Zip Gt $G) &7C(' 5 -IIl2-/ I CONSTRUCTION WORK TO BE PERFORMED: 'Note: O#slle Borings/Welis Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFIF ATIONS ❑ MONITORING ❑ HOLLOWSTEM BOPJNGDEPTN vul ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporfWaleg ❑ HAMMERIDIUVEN CIA.OF BOREHOLE ❑MULTIPLE CASINGS El MULTREVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 0 SOIL ROPING �❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Bourg Dia: Cadng Dia: Casng Dope: ❑ INJECTION Leaauaxom s) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE If OTHERDi°,.LTttL OTHER�[iL(L GROUT SEAL PUMPED? ❑ s ❑No (Nde:Madmum F,/ fal Dep I530fo rI WELUSOILBORINGIDs -pl GROUTSPECIFICATIONS (Y/Yi_D7 pq Nre�erre c� 'ODE U0 9rW0R q W e(\5 E\\o�d a1�_ J �t +b STRUCTI N WORK BE E FORMED: m st °b. ESTRUCTION METHOD:(CHECK ALL THAT APPLY) • t 5 to (< +adtdL #WELLS TO BE DESTROYED " "fee "'#6;" ❑OVER•BORE DIAMETER of_Inches to depth of_feel C21av"t t WELL IDs PRESSURE GROUT To depth of_feet below surface ho more- -fktn GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feel below surfaceby vI2, '-EEO TREMIE TYPETOBE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel beiowsudace if>3 feet CO MENTS: SOiI 66rIn55 anti. 1$GYG}� WOL•4-m.r 604h u3 •L i Lb- Wi IA Jr' ¢ e`.raU� .. O a4ch6 er. kar 746 t -3 MP &flaQ A t &Pr/ 1 hereby certily that I am authorized to complete this application and that the workwillbe done In accordance with J Signed S Joaquin County Ordinance Codes and Standards,Title/Comppanypll other iapplicable ¢h:,able California6` �// Pint Coic pri'I(,Y1r, Print Name AA/'IGl reen Date / -7-1-Zt( GI(. M J ARM NT USE ONLY T Application Acceptgd'By d—k —- Dale Issued: 10 Grout Inapecllon y/Datea. Destruction Inspection By/Dales: Facilil /Site Information FA Name FAAddress 1 200 tk 55 I FA# I PR# FA PE '55 C Ctj,Ay'toff Reviewed By I Work Plan Dale 2 DMf C57 ❑C57AuUWza0bn1mrOd1sr1oSUn Per ❑Woftes Comp ❑Wodwes Camp adm tPema ❑AaessA#rewwwd LeaftoscyApprowl CO E TS/COND TIONS: t�v-t�r qMaImco vTC rS 0kr o ns pco M r ' AAy �i^JZ o4e P /p p :.ft_ aMo ;s d ;ll to kAQ.CCn`V- fer- M1=R�K� ��r fq��— . bor Jt Hw ,be ed- . — - 1 ✓«. �►fuN K vS;v� 4Q- - ctK-d-- WPTVPE P I SC ';FEE INFO AMT RiEmiTTED1 CIfECK#I RECV'D BY TE WELL PERMIT# I INVOICE# Permit p 5 313 X ggCL I 'JW 2 ZR,7 Vj 1 4- * Ig5/-f-Iq -- -tCl 52ZL�-crC53-1z- 1868 E. liazelt n Avenue I Stockton, California 952 5 W T 209 468-3d90 1 F 209 464-0138 1 WW cehd.corp 029-ot7ol-zozs � f(Jv /Tts 4Pe� �2 �: fib �o y o{ �arSOtiskatsuse� �ellPerm / am/20Zt�