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SAN JOAQUIN Environmental Health Department <br /> •- COUNTY• <br /> Greatness grows lirr.. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remedlatlon <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> LNS Application Is hereby made to Son Joaquin County for a permit to construct and/or Install the work described. <br /> This application Is made <br /> 7-madee�In compliance with San Joaquin unty Development Title,Chapter 9-1115.3.and the Son Joaquin County Well Standards. <br /> -7 Job Address z`T Ss1 �ll S+(Pp cltyistodemp S'+oC�I l.-h <br /> -r , "" Phone <br /> Cross Street A APIM �7 rr <br /> Properly Owner• CL' e C,}et'10go IN4^ 11-01 Phone c.;i-1-5i�'S�75-- <br /> Address4W E, �1c� elP0f —HIVE City/stetelzipsdnLfo. 5S 7— GG /� <br /> C-ST Contractor l Sn CN 1 INS Llcenseq �� Phone�lb —� 53- 6010 <br /> Address 1t3S9 Mnvi,-tr FArK <br /> It city/statemp -LGv GPr oval CA- c?S9'(CL— 4-0-666-933 <br /> Consultantsub-Contracturlrt es+0w SO ti m1Ur 'T„Cn Ucenseg A HA-T1 5?—I �-3`I Phone �5 <br /> Address? g-f A.-(Inca P . 5-1rt -1 w�1 CIty/State/ZIP C9K000'J U- �lfS20 OciI <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: ORelte BorfngslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLRIORINO NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATI UB <br /> ❑ MONITORING ❑ HDLLOWSTEM BORING DEPTH T f B(BOLTEO TRAFFIC BOX ❑STOVE PIPE <br /> ❑ CTION(Vaporlwater) ❑ HAMMEM�RNEN DIA OF BOREHOLE 7— ❑ ❑i`1 MULTIPLE CASINGS MULTREVEL WELL CASING DIA <br /> APGRPROB� MUDROTARY CASINGTHICKNESS TYPE OF cAsim❑STEEL❑PVC❑OTHER <br /> SORBORING T PUSH POINT(Opt CPI) CONDUCTOR CASING ❑Yes No Bella DID: Cm NDa: aDepee <br /> ❑ INJECTION Vksm ,Qo l ❑ HAND AUGER GROUTSEALDEPIH TREMIE TYPE TO REUSED:❑AUGERS❑HOSE PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Ym ONO (Nole:Me:dnamfrmfe)l Depthb SDFO <br /> INEW$OIL BORING IDS OROUTSPECIFICATDNS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METNOD:(CHECK ALL THAT APEW <br /> If WELLS TO BE DESTROYED ❑OVEWBORE DIAMETER of_Inches to depth of_feel <br /> WELL IDs ❑PRESSUREGROUT To depth of—bet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_lo_feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS HOSE PIPE MUSHROOM CAP 3 feet below Surface or feel below surface If>3 feet <br /> COMMENTS: <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> ��A��A,,,,js////����rrrr San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed d Title/Company Sl+ir/ �II;rL� /14,G /W(.rTMe Sr�v71h) <br /> Prim Name fi�jCt ,rovtr Date tt-- 2 `i--201 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: /✓A6 bL-,e.r Date Issued: <br /> Grout Inspection By/Dates:Destruction Inspection By/Dates: , kredt ` AV 7 17-17 <br /> Facll /She Information <br /> FA Name FAAddrem /6/,�S• SU s t` FAO Z53 PR# <br /> FA PE WP ReNswed By AV*tt•+ Work Plan Date <br /> OUT CG7Aft1tZ fflforOhFto Slgr PamA EirW~SCWV ❑WeAere CanrWdrew EaaoedneMPemA ❑AwmeAereanenl mdAtimyApprwd E21FR <br /> COMMENTS/CONDITIONS: 13G AzG ✓'y� /t�/'¢ r�""'� `�H <br /> IWPTYPEI PE I SC I FEE INFO AMT REMITTEDI CHIECK/A I RECVD BY I DATE I WELL PERmrFw INVOICEM <br /> Permit Z9dS- 313 8182X 3 ySGa/ 1 11776 A.q G-�,`•r9I dAp3? 7 7 <br /> 1868 E. Hazelton Avenue l Stockton,Celifomla 95205 l T 209 468-3420 l F 209 464-0138 1 www.sjcehd.com <br /> EM 29e109.0147 t�/[rJ•'OA� yP' '� /OQ.f nqSoho Mdlaavon Was PmnaA pawn <br /> coy 2443 33 *0767 <br />