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SAN JOAQUIN COUNTY RECEIVE® <br /> ENVIRONMENTAL HEALTH DEPARTMENT APR 19 2017 <br /> 1868 Hazelton Avenue.Stockton, CA 95205-6232 <br /> ' Telephone:(209)468-3420 Fax.,(209)4683433 Web:www.sicehd.com ENVIRONMENTAL HEALTH <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION PERMITISERIACES <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hanahy made to San Joaquin County low a perm4 to ConitnKd andlor Ritual the work described <br /> TMs appucawn Is made In compliance with San Joaquin County Development This,Chapter 9.1115 3,and the San Joaquin Conary Well Standards <br /> Joh Address -6()Y5- tiro UIOnC.O a.0 C141stal op 56uK}on J2 95219 Phone 20 1!1 95Z- 10oo <br /> Crosti sb"l we -9 mr 1C. P,A APN 6660 SO 3 O <br /> Property Owner _. & ,Qr L✓2r er Phone 310 363- -775 <br /> Addrass _ ZSSo-- y,� To-is, ._ S3r fe� 213 DleyrstawaP P1,,s Uwies CA 9027y <br /> C-57 Contractor Gra9: Dr, Ilr -B !ps'f/ne ?ne. Uansa/ -15516 5 Phone (9Z5-`i 313 Tliv <br /> Address _� j6ol, _ Rd.-._--__ Cltylsutamp /%r4,-l;%,CA - 455 <br /> ConaulUnflSufHContraet« PGS_ iJ+ rpnn.O,fa/ Tne- Lteanaea Phone W.5 1121?-/960 <br /> Address 7(o- - ReCLVOd_ ,/,i _. 2,,; 2oD ckylsnl/mP /Vja�n Cr4 9Y9`1S_.__ <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note OfW,[a BOON&Web Requim Acaass Agreemanls wEnaoaclenerdPanMts <br /> TYPE OF WFUMRNG NUMBER INSTALLATIONT'/PE CONSTRMIONSPECIRCA710N5 <br /> 0MOM1~ _E3HOLLONSIEM 1TO BOraOEM ^-20' ❑BUTEd1 TRwM BOX E3 STOVE PPE <br /> E3t:xTRAcnoN ryevaNvmd O wwuERMWI + Mk OF BOREHOLE A., p ULKTFIE CASINGS I]TMTTREVFLwT31CASING CIA <br /> 0SOLVAPORPROBE ❑ MWROTARY CASNGTHICKH.4-TYPE OF CASING OSTEEL 15 PVC 00THTai rte_�d �Os�A.� <br /> SMBORWG 'T--13NE 13 RW PO (GPI OFT) COWUCTORCASe1G QYa No hairy Dia CaYgw: CZ04 ORIF ie a1P IC <br /> NRChON wins om,.i [3 HANDAUGER GR=SEAL CEPM TREMIE TYPE TO BE USED O AUGERS 0 HOSE O FRE G-t'✓ <br /> ❑ OTHER OhCI'IR.L).:;�..t GROUT SEALRAPEDT ❑Y.,M No aqui'Cheam F:wbl Dwa b n30 <br /> Y4wSOLSORINGDs P, crOUTSPEtPCATIONS 2 'f )o jbg g.E//D <br /> MCdad <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> I WELLS TO BE DESTROYED .3 ❑OVER41GRE D"IETM of_hdas b depth af_kat <br /> WELL IDS ,<ncr ., PRESSURE GROAT Todepthof 7.0 kelbelowaelaa <br /> GROUT SPECIFICATIONS :-rm c, EXPLOSNES Fmn_,_b__kNbbwsWw <br /> TREMIE TYPE TO BE USED L:lAUGER5LjHOR3xP1PE 0 MUSHROOM CAP 0 3kN 1000019111201 kelbabwsurfwt B>31eet <br /> COMMENTS: (C- Vjl w' 11 -7T�ini e Pr%,acl P255.+rZ W, // b e /�'ho�'✓cC tl <br /> -� r,e-edc <br /> I hereby carti fy that 1 am authorized to complete this appDcaUon and that the work VIII be daM In*=orcumm wlth <br /> �q� San Joaquin Cowry Ordinance Codes and Standards,and all other applicable California lewa, p <br /> Signed_..-1SLreo -- TiBdCompanySen,or Skw <br /> Prim Name <br /> DEPARTMENT USE ONLY <br /> Appleadan Accepted By. - ' Dote Issued- <br /> Grout Inspe don By/Datn: <br /> Destruction Impection By)Datm: <br /> I 1 <br /> FA Namer✓ <br /> L . FAAddIw "(,1CS�' / . -,,., FAA Z -7 PRF <br /> I,z- <br /> FA PE C76 WP Reviewed By wo*Pion Dab 11 /C 7' .--Y I /7 <br /> 0 r,S7 ❑Ywwscaw Owwuw,Cawwaw OENoaaam PRM ❑Aconi ire Lits MA"Aw" UW <br /> ONME SICON TIONS: <br /> SR TYPE PE I SC I FEE INFO JANT FtFMMDI CHECKS RECYD BY DATE I SERVICE REQUP9TB INVOICE/ <br /> Permit r ')S 1392 ,�i-<, 'r`-. )V7ZJz <br /> 3 � y/ 7 s' 6y3 SL- 00770E, <br /> END 79-0110.26.2075 Site MYpationww Pont Application <br />