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SAN JOAQUIN Environmental Health Department <br /> COUI Y <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 /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance v4th San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 23659 South Santa Fe Road CltylStatelZip Riverbank,CA,95367 Phone <br /> Cross Street Henry Road APN 249-070-100-00 <br /> Property Owner' Jose Cano Jr Phone (209)480 4365 <br /> Address 23659 Santa Fe Rd City/StatelZip Riverbank, CA 95367 <br /> C57 Contractor npro a inc License# C 1012248 Phone 530 693-0219 <br /> Address P.O Box 6093 Cityistatelzip Orovllle Ca <br /> Consultant/Sub-Contractor Recharge/Michael Harris License# PG#8841 Phone (510)432 4773 <br /> Address 535 Mission St 14th Floor City/State/Zip Send Francisco, CA 94105 <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsNvells Require Access Agreements or Encroachment Penults <br /> TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 35ft ❑BOLTED TRAFFIC BOX ❑STOVE PPE <br /> ❑ EXTRACTION NapwMlater) E1 HAMMER/DRNEN CIA.OF BOREHOLE 2. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER NA <br /> Q SOIL BORING 5 ❑ PUSH PONT(GP!CPT) CONDUCTOR CASING Yes ❑Na Boring Da: Casing Oie: Casing Depth. <br /> ❑ INJECTION A,Sea.. ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER. GROUT SEAL PUMPED? ❑Yea ❑No (Note:Maximum'nsfall Depth Is 30 Fg <br /> WELL SOIL BORING Os RH.1 through RH4 GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELL IDS []PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE []PPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if feet <br /> COMMENTS: <br /> hereby t authorized to complete this application and that the work will be done In accordance with <br /> oa my Ordinance Codes and Standards,and all other applicable Pallforl laws. <br /> Signed TitWCoommDanv //2 _ <br /> Print Name Dat,, /'14/2622 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> FacilibitSite Information <br /> FA Name FA Address FA# PIRS <br /> FA PE WE Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authoixabi n far Other to Sign Permit ❑Workers Camp ❑Walkers Come Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE P��l <br /> E INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit <br /> 1868 E. Hazelton Avenue I Stockton, California 96206 1 T 209468-3420 1 F 209464-0138 1 WWW.Sjcehd.com <br /> EHD 29.01 N1-0 7 Site Mitoon Well Pemdt Application <br />