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SAN JOANN Environmental Health Department <br /> - COUNTY--._... <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 andlor install the work described. <br /> This appl3 gGgg3is made in compliance With San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 2365(3 South Santa Fe Road CltylStatel2ip Riverbank, CA,95367 Phone <br /> Cross Street Hsnry Road APN 248-060.090-000 <br /> Property owner' City of Riverbank Phone (209)480 4365 <br /> Address 6707 3rd Street C1ry/Stotelzip Riverbank, CA 95367 <br /> C57 Contractor Enorobe Inc License# C57# 1012246 Phone 530 693-0219 <br /> Address P.O Box 6093 citylstatelzip, Oroville CA 95966 <br /> GonsultanUSub.Contractor Redhorse/Michael Halls License# PO 1188411 Phone (510)432 4773 <br /> Address 636 Miseion St 14th Floor Cityistatemis Sand Francisco,CA 94105 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: ORsae BoringsA7dells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELLI00RIN6 NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 35B ❑BOLTED TRAFFIC BOX ❑STOVE PPE <br /> L] WRACTIRN IVaparNlela) El HAMMEWDRNEN CIA OF BOREHOLE 2h ❑MULTPIE CASINGS NULTREVEL WELL CASING DIA <br /> [ISOILVAPORPRO09 b MUD ROTARY CASING THICKNESS TYPE OF CASING- ❑STEEL ❑PVC ❑ OTHER NA <br /> LL7 SOIL BORING 1 ❑ PUSH PONT(GPI CPT) CONDUCTOR CASING ❑Yes ONO acang DID: Ceskg qs: CWntlnd* <br /> ❑ NJECTIONukswradoiaal ❑ HAND AUGER GROUT SEAL DEPTH TARMIE TYPE TO BE USED. (]AUGERS ❑,sHOSE ®PPE <br /> Q OTHER ❑ OTHER: GROUT SEAL PUMPED} ❑Yee ❑No )/aa��dr.N.Lam Fray/^�Ra�pl�hi,a,t30�FlJ <br /> WELUSgI BOmNGitk RH5 GROUT SPECIFICATIONS if/O/A�_ /z�frr-l-fs <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_lnchesto depth of_feet <br /> WELL WE ❑PRESSURE GROUT To depth of—feet below Surface <br /> GROUT SPECIFICATIONS ❑EXPLOSNES From—to_feet below surface <br /> TREMIE TYPE TOBEUSEO El AUGERS ❑HOSE PIPE MUSHROOM GAP El 3 feet below Surface or feet below Surface if53feet <br /> COMMENTS: OH-site boring <br /> I Toby tind 1 am authorized to complete this app#catlon and at the work will be dome Ina enee w th . <br /> uln County Ordinance Codes and Standards,and all other applicable C11001rlla laws. L <br /> signori Titlolcompsny �1.,UA 4)I���� rr�� <br /> Print Name Dennis tt oats 04 /14/2022 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: ✓� �� <br /> Grout Inspection Bylostes: 22 <br /> Destruction Inspection By/Dates: C <br /> F 1 ' 8Heinformation <br /> FAName B a rrW j g&'r- f FA dress Z 5Q S FA# 00 2 I PR# O S l('�' '�3 <br /> FA PE Zq b WP Reviewed m- WoM Plan Dare '00 <br /> 1 0C-S7AudW dmWOUanto BgnP wa ❑wawacanp ❑Wak9es CanpW2w,r ❑EmozdmenlPami[ AareemaM AgengAppwal MFR <br /> COMM NTSJCONDITIONS: �� ; a �,� ► fsu S © h ; IDro1)D <br /> +o efil) For- C' dt(( Stct DO,, s 13 . q-. Z <br /> WPTYPE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICEA <br /> Permit ZQ O 313 152 x ,5Z ,J `�'��✓� W? 00tt3l 80 <br /> jW f 4-2I a-i-5" S� oo SS -Z <br /> 1868 E. Hazelton Avenue i Stockton, California 9 05 i T 209 468-3420 1 F 20 464-0 ei3, ir-1lmwvulell cplmn om <br /> EHD2 11 W.ea-0] j <br />