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►N+IA, l t'Z <br /> SAN J O A Q U I N Environmental Health De artment <br /> COUNTY RECEIVED <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION SEP 2 Z 2017 <br /> For Wells and Borings Used for Contaminant Investigations and RemediaONMENTAL y�TM <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ERWISEROCES <br /> 48 Hours Advance Notice Required For All Inspection:-, <br /> AppSc0on M hereby made to San Joaquin County kw a permit b corntruct w4or katal the work described. <br /> This appkation b nude in campsenoe Wtth San Joaquin County Development Tpe,ChapW 9.11.{15.3,and the San Joaquin County Wei StandaMs. <br /> .) <br /> Job Address 1 Z.Oo l S. FL l-{ cityestatelzip 1 o•�l e c a C/ Phone Z'0 Q-8 L`/ 36IP <br /> Grose streat Fre,,eA C4--At APN r'U�f- 0&_- OSO <br /> Property 0wraw' C_ i` a-Fo r a-0"r �w Phone Z 02 <br /> Address 1L vo 1 S, , cuyl towzip I'"J..c.• Ci4 Is-31 L ---- <br /> Cs7Confractor_ Dr: reqCo. Trtc. UceneM W C) Phos. 07-3 Y—Y300 <br /> Address "o ` d cityrstatemp re n cA i YS 7 1 <br /> Canty "J s,. oti. XLicen"S n�^ Phone LOT 2'.(3-1/.S"O <br /> Adarss -,c)3 2 s lr S t d 3003 cltrItat.mp - -- — <br /> CONSTRUCTION WORK TO BE PERFORMED:'Now Of ho BoTtTpwwoft Require Aoom Awewrmft or Enaoschment Permits <br /> TYPE OF MYELLBORNQ IWALLATION TYPE COMMMON RE02UMNSZ rr <br /> "Tom13 HOLM M l FOG OMM _`(•J' ❑&XTm TJT M SOX WLSMVE RIEDQRACIIOM ek arwsm ❑ WAGWWWAN nit OF 80Fe tE K " ❑MLL7r E CASMCd❑NIL7kEVEL WELL CAM CIA <br /> ❑tial WW PWN ❑ MA WTARr CAM DION SS f C l{ Y o_TrrE OF CAttM❑STEEL m PVC❑OMR <br /> ❑90LSOF S ❑ PUSH POMR IOW CPI) carotC=WW ❑rad{73I Ns "Dix Csf Ok---- GNW DWk <br /> ri - <br /> ❑ RJEcraMtomm goo l ❑ HMO MOM GWW SM DEPTH 21 TWA TYPE TO BE UBM❑AUGERS❑HOSE�PIFE <br /> ❑ OTHER p OTHM._ GF4WT SEAL PIM PW7 iS YN❑No /MR Jrararw FMW 0"M 30 F j <br /> WELU SOL SI ID< la 1(�-I t� deur BPecF7CJ►rNONie �j emE Com.—.,�t <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPL)I <br /> I WELLS TO BE DESTROYED ❑OIIER41ORE DIETER of bars b daph d iat <br /> WELL& ❑PRESSURE GROUT To*M d tut blwr alba <br /> GROUT SPECIFICATIONS O D ROSNES Fraa to bet blow w1ow <br /> TREAE TYPE TO BE USED AUGERS HOSE PIPE Ej Mt1SFROOM CAP 3 bel bdow alba or bat bolo.tuba k>3 bet <br /> COMMENTS: <br /> i <br /> I hereby certlfy that I am authorised to complete this application and that the work w111 be dons In accordance with <br /> SanJ�t7 �-•-'�C«�nty nonce Codes and standards,and al other kabb fornia laws, <br /> Slip . .a l.✓ ,! n Ciao <br /> Print Name 01,C4.X I-. A(c,4- Dab ?/7 t !� <br /> RF�OTMENT USE ONLY <br /> W. � �: f tete Issued: lz I <br /> CwvA knpedlon BpDaw: _.. <br /> Doo ucdon krpeclion ByMalw <br /> Fa li <br /> FAN,, �s rw^��`^ J---Y-Z S FA A" IjpO� 5 . FZw FAI coz, ti•' Prj 0,511 (+� 'tI <br /> FA PE " 110 J WP RsMewed By _ Wodt Pin l>rte JT / 'I I <br /> [I= Q C V AsiMkdal Iw 0@W b Np P0o4 ids Cara ❑%1ojw%Ca w Wdrar ❑ffeleadwral Paws ❑Aunty Adan N Df0W Apo:yApVM ElfAR <br /> t MMENTSICONDIT10Ns: <br /> WP TYPE I PE SC I FEE INFO JAMIT REM"TE01 CHECKS I RECv'D BY DATE WELL PERM IT11 INVOICEIF <br /> 1888 E.Hazelton Avenue I Stockton,California 952051 T 209 4138-3420 1 F 209 484-0138 1 www,sjcehd.com <br /> EM 2"1 ae-0t-11 ab Wpdm WM P&m*ApFtraeon <br /> W t' 2AO; 1_17$ ls2 X 3 �tsti 1510 S fV0-1 .11 CI C1 <br />