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W JUAOUIN Environmental Health department <br /> ---COUNTY <br /> If c59 :, _ . I 710 <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) 953-7697 For INSPECTIONS <br /> Appl the work described. <br /> This application is made llin compliance with Joaquincation Is hereby made to San <br /> ith Sant aquinCounty Devlelopment Title,Chapte for a permit to rr9.1115.3,uct ancitor Iandlthe SanJoaquin County Well Standards. <br /> Job Address Itf " ' CCU $IILrV �1 'city/Statealp `ihx r-'(-��n <br /> �� Phone <br /> Cross Street LCI /n1� . 01700 1APN <br /> Property Owner` ` LA4-e - -� S- �.II b� ' Phone .262-y� r - 7l`94 <br /> Address 1 C1 f/( r , Cit /State2l r- �s Lr J c o— <br /> C•57 Contractor E CC-��r� f" ( hlSO i .�nC' . License# f 5� - 4-1( 3 G S Q-R Phone 91Le - a`- <br /> Lom .2 <br /> Address -5WO Ce' I�alWli Of', -�-7C•C CltylSfalelZ(p �1�/�C-I1[f (`CYi��t/�, CA cIS�( (� <br /> ConsultanUSub•Contmclor License# Phone <br /> Address City/StatelZip <br /> CONSTRUCTION WORK TO BE PERFORMED- 'Note: OHshe BoringsNJells Require Access Agreements or Encroachment Permits <br /> TYPEOFWELUBORING NUM OE INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ moNKOWNG Q HOLLow3TEAI 80NNG DEPTH IO �- ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTKKe WapaM'Mer) Q HAMMERARIVEN DIAOFBOREHOLE 1. }5 A . 0 MULTIPLE CASINGS Q MULTI{EVELWELL CASING OR <br /> Q SOILVAPOR PROBE ❑ MUDROTARY CASMGY'RCKNESS TYPE OFCASWG: ❑STEEI- ❑PVC ❑ OTHER <br /> �SOa BORING 21 PUSH POINT(GY CPT) CONOUCTORCASING ❑yes QNo eoey 011c Caskg Dia: Cxskg p¢Pp: <br /> ❑ NIJECf10N1Arsoa¢e o,rc< HANDAUGER GROUTSEALDEPTH TRD.VE7YPE TORE USED: ❑AUGHIS ❑HOS ❑PIPE <br /> ❑ OTHER ^—Q GTHER: GROUT SEAL PUMPED? QYes QNo (Not:Madm Fr¢eWODePthl 3OFq <br /> WELUSOIL BORING ID; GROITSPECIRCATIONS <br /> �—�1�'1r��i etb <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY - <br /> 9 WELLS TOBEDESTROYED ❑OVER-BORE DIAMETER ofWELL _Inches to depth of_feet <br /> GROLITs [I PRESSURE GROUT To depth of_feetbebylsudae, <br /> GROUT SPECIFICATIONS [:I EXPLOSIVES From_b_(eel belav sudace <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOMCAP 0 3 feel betas'sudace or lealbeimw surface if>3 feel <br /> COMMENTS: <br /> 1 hereby cerlify that l am authorized t0 complete this appllcalion and Thal the work will be done in accordance with <br /> ,r� San yqui�r/s,�,ouunnly Ordinance Codes and S?Ng rds,end all other applicable California laws. <br /> Signed /ti�ro%��f11'/�ie�G� iP/yE,y A9A GTIdaJCom an AC e�4ned / ✓e•een <br /> ��77 P Y141s/F •/� tin ldir.�r( I nb J Il+a ?f. <br /> Print Name /c0 a/7L ArB/ /�l, jry( .a �� Dale—­L.- 9- Z po'j 3 <br /> 7 USE ONLY <br /> Date Is ued: <br /> Application Accepted By: i/1(L <br /> Grout Inspection By/Dates: n <br /> Destruction Inspection By/Dates: <br /> cilil /Site Inform than 1� <br /> FA Name i — Addreess VAO¢r s �d ' GL(. FAa O '> (�JC' pHp <br /> FA PE Z9 MP Reviewed 8y Work Plan Date 8 a/2 > oil <br /> 57 OC-57Au@adeae¢nlar0aerlo Sk.Pemal OWadnsComP OWakees C.mp Waher ❑Ergroadmenl Penal ❑Access Ayeeamm ❑lead Agonry Apmovi IFR <br /> COM ENT ICONOITIONS: '4 t^ Cie- O JS 5 Y t1r t vri l <br /> eTmkd'AS r ,�mel r�i� " I,DV rs " rl s� o�� r 3 hd ,rs a')tl l 1 d . <br /> Wp TYPE E C F NFO AMTREAU ED C ECK# RECV'D BY GATE WELL PERMIT# INVOICE# <br /> Permit S a x G C 0' L 20ZUFO 0 <br /> 1868 E. HBZellon Avenue I tocklon, alifontla 95205 1 T 209 4 8-3420I Z2019464-0138 w 'Sj eh .c rn <br /> EH020.91 a-2.V ♦ (il <br /> ��f// CC C'.A Sea A6fgaaon W¢Il Perrtll Appkeaem <br /> L <br />