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> <br /> Environmental Health Department <br /> f jpe `li i <br /> 14 1+ ,� _ coUNTY— <br /> r�ere Greatness grows here. <br /> SITE Mand eATn�s used folr & BORING PERMITcontaminant APPLICATION <br /> Remediaati n <br /> For Well <br /> Nor' :S Advance ENoticePRequired For All Inspections <br /> 48 M• permit to construct andlor install the work described. <br /> Application s n it,San <br /> to San Joaquin County for a pstandards. <br /> sir San Joaqui� ounty Development Title,Chapter 9-7115.3,and the San JoaquinP county Well <br /> This application is madein comF;la^' Citylstatelzip 9— <br /> Job Address ` APN f j—3 AL6 - — Phone l�-t --D <br /> Cross Street 3 q <br /> Property own*,* citylStatelZlp <br /> Address , I_ License# R q 7NZ <br /> C-57 Contractor I CltylstateRip Hr Phone <br /> •� r License# <br /> Address � CA �56R <br /> Consultant/Sub,Contractor CitylstateRip dH'Lf-'rl� d r <br /> Address o <br /> r <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Ottsite BoringslWells Require Access Agreements or EnuoacSmD�P Permits <br /> (PE ❑BOLTEOTRAFFICBOX <br /> TYPEOFW� NUMBERO HOLLOW BORING DEPTH ON SPECIFIC❑MULTIPLE CASINGS 1 MULTI-LEVELWELLCASING"A <br /> — <br /> ❑ MONITORING HAMMERIDRNEN DIA.OF BOREHOLE�.n,PE OF CASING: STEEL OPVC OTHER DePftCl CASING THICKNESS CasiRq Die: <br /> EXTRACTION(Napo MUD ROTARY <br /> ❑ SOILVAPORPROBE PUSH POINT CPT) CONDUCTORCASING Yes ON, BoNq <br /> ❑ SOILBORING HAND AUGER <br /> GRNDWTO CASIN TREMIETYPETO BE USED: ❑AUGERS —PIPE <br /> ❑ INJECTION PY a OTHER: <br /> GROUTSEALPUMPE04 ❑Yes ON' lNois.Me&=Freetall Deplh is 30 FI <br /> ❑ OTHER � GROUT SPECIFICATIONS <br /> WELD SOILBORING IDS <br /> DE TRUCTI NMETHOD: CHECK LLTNin�PP <br /> odepth of feet//. <br /> AVER-BORE DIAMETER of� <br /> DESTRUCTION WORK TO BE PERFORMED: N lest below sudace <br /> #WELLSTO BE DESTROYED PRESSURE GROUT To depth of`o—feet below surface <br /> ❑EXPLOSIVES Fran feet below sudace it 4 feel <br /> WELL IDs f�W I I Sar w ..A- `� MUSHROOM CAP ❑3 feel below sudace or <br /> GROUT SPECIFICATI NS <br /> TREMIE TYPE TO BE USED AUGERS HOSE PIPE <br /> lth <br /> COMMENTS: <br /> 1 hereby Ordinance Codes and Standards,and all other ap ,cable California laws. /AEG <br /> certify that 1 am authorized to complete this application and that the work,cal l e done in a laws. n�cJe w <br /> it n pain County 0 N viN✓I <br /> /+ Z Title/CompaP �� 5 <br /> Signed L .1 r, c 0 Date - ra <br /> �I Print Name C N <br /> DEPARTMENT USE ONLY Date Issued: <br /> Application Accepted BY: <br /> Grout Inspection BylDates: <br /> Destruction Inspection BylDate ._ FA# 023 L?J$ PR# 17,:O(ol O <br /> Faclll (Site Information FAAddress �,. �/� <br /> e Name �'�'� A SO.�ri Work Plan Data <br /> p WP Reviewed By <br /> FA PE l�rll, orkefs Comb ❑Wmkefs ComDWaiver ❑Enaoachmenl Perma ❑Access Agreement ❑Lead A9e�rrY ADD�n'�I F <br /> ❑G57 [ 57 Authorlratan fa OUcer to Sign Pemnl r Casr t /.0 f�COMMENTSICONDITIONS: A40/ f. %d V <br /> i�Or, C / OW I����l�� <br /> 1, we— * INVOICES <br /> Per�+ik �' DATE WELL PERMIT# <br /> PE gC FEE INFO AMT REMITTED CHECK# RECV'D BY ��9-4 �Poo3y(/13 <br /> WP TYPE x 1&0-00 ySNSZ .�L^X <br /> Permit Z.Ao1 •b%3 $152xff 09464-0138 I slaa'S1.M1andrw m _ <br /> Stockton, California 95 05 i 209 46�-3420��' a,•rWpil ea <br /> 1868 E. Hazelton Avenue I b q t L it y�¢cn >m s-37 <br /> }) EHD2eA10"i-T7 �IyZti ,W 4Sfr2 'rc <br /> P s kszK 3 <br /> w <br />