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SAN�JOAQUfN Environmental Health Department: r l —COUNTY— Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 9L-11115.._3, and //the San Joaquin County Well Standards. C�// Job Address l vi �Lh lD�� E 1 (V an city/statelzip S IVU� lN1 r VO Phone 0 `/ / Cross Street APN ,) ry, Property Owner' L c Phone O1/_ q Address S City/State2lp S�C,�CkN V7' ��U2 License# O ?� C C-57 Contractor Q �11 f /.' Phone /��O'-.Jm3—q�SJ Address i City/State/Zip cal 957NZ -��(o//—Old�.,`/ ` License# Phone �3 0-4 Z ConsultanLSub-Contractor US Vi � � � � Address D C nY( Svi P 6 City/Statelzip Crr, W Pao ' (A •-_S/ Z CONSTRUCTION WORK TO BE PERFORMED: *Note: Offske Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS [I MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX [I STOVE PIPE ❑ EXTRACTION(Vow/Water) ❑ HAMMERIDIWEN DIA.OF BOREHOLE ❑MULTIPLECASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPEOF CASING: []STEEL ❑PVC ❑ OTHER ❑ SOILSOMNG ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING I]Yes [I No ending Dix: Cashq Da: Casing Depth: ❑ INJECTION Wrsosaa.omnal ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETO REUSED: [I AUGERS [I HOSE ❑PIPE ❑ OTHER _❑ OTHER UT SPECIFICATIONS❑Yes ❑No (Note:Maxinm u Freetall Depth is 30 R) WEWSOILBORINGIDs —GROUT J _ _ p DESTRUCTION METHOD• (CHECKALAPPLY) DESTRUCTION WORK TO BE PERFORMED: TU #WELLS TOB D STROYED2 OVER-BORE DIAMETER of_inches to depth of_�� _WELL We Ur m w— ❑PRESSURE GROUT To depth of feel below sudace GROUT SPECIFICATIONS -e,a MrK ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED AUGERS ❑HOSE PIPE I MUSHROOM CAP ❑3 feet below sudace a feet below surface if>3 feet COMMENTS: I hereby certify that I am iii to complete this application and that the work will he done in accordance with p' Q San Joaquin County Ordinance Codes and Standards,and all other(applicable California/1pw �� o Signed JG�'W iJU Title/Company P/OJed InM'Iagi —5 di�5 s. 4(';fi9)q✓/ j4 ky Print Name - ,'L o��. r Date '1-I(0 DEPARTMENT USE ONLY Application Accepted By: ��^ A Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facill /Slle Information FA Name FAAddress (a LIJ F , FA# L90L32Z$ PRO VSjol;.10 FA PE WP Reviewed By L -x Work Plan Dale y `I 'Z ❑C-57 C57AUIhWWdonfor Olherlo Sgn Permit orkeis Comp ❑Wodcer'scomp Waiver Encroachment Permit ❑Aooass Agreement ❑lead Age(q Appmwl R COMMENTSICONDITIONS: B . VfY /J ry��" /1!H « 0";V" Wi WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# PermB 2yoz 313 S15zx.,T,. 3tlN f5'2 AlA q / 1868 E. Hazelton Avenue 1 Stockton, California 952051 T 209 468-3420 1 F 209 464 01138ation 1 www.ssjWON p ceehdd. om Sitlication EHD 29-01 gaol-17 WP ?9bc3 S'Z,3 $152X3 44% HSBS� lac H�u�W SF -0690S31