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S A N J OA Q U I N Environmental Health Department 1`'sl'_ ) — COUNTY—— `•s•.Irrl-,' Gn:rNncss gnrt';s hrrr. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspectioi:c CALL (209) 953-7697 For INSPECTIONS Application Is hereby made to San Joaquin County for a permit to construct end/or Insioll the work described. This application is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 3v3'L City/State/Zip- 5�-vVN1 CIS '157uC Phone Cross Street APN _i1-13- I�lo-3CU-C)(U Property Owner' (��.e.��wr�\ Phone Address 1`)A'L0 St-- Cityistate/zlp IUrw(r,S)I\a L.) aY 10 59 1 C-57Contractor_ G„ Llcensoft I CJI Z.ZIIK Phone SZD- Z01`t Address ,p. Q�'0�f. L Ur13 City/Stale/Zip OyoUt\kt ConsullanUSub-Contractor_ -piX- : Llcensell Phone `111- `'II-J xMI$- Addross Wt-r1% IVk)n\ S Ua% City/StatelZlp �aotr� ��ur/ C/� C%•fL=ll ��ryl,, + \Irks CONSTRUCTION WORT(TO BE PERFORMED:'Note: Offsite BodngsfWelis Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑ HOLLOWSTEI.1 BORING DEPTH ❑OWED TRAFFIC BOX ❑STOVE PIPE ❑EXTRACTIM(VapalA9atu) ❑ HN,161ERIDRNEN DIA.OF BOREHOLE ❑IKILTIPLE CASINGS❑I.IULTLLEVELWELL CASING DU ❑SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:❑STEEL❑PVC❑OTHER ❑SOIL BORING ❑ PUSH POW(GPICPT) CONDUCTOR CASING ❑Yes❑No BWN DO: Caslag Ma: Casing Depth: ❑INJECTION(&yswroa.o,enel ❑ IWO AUGER GROUT SEAL DEPTH TREAIIE TYPE TOBEUSED:[]AUGERS[]HOSE []PIPE ❑OTHER ❑ OTHER: GROUT SEALPUl,IPED7 []Yes❑No (Note:Lladm rn Free faT Depth Is30n) WELD SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY T N WELLS TO BE DESTROYED 21.1 ROVER-BORE DIAMETER of Inches to depth of feel WELLIDs 0)IJ-1'mw-t- ,, w- - rIT Nr -G ®PRESSUREGROUT To depth of feet below surface GROUT SPECIFICATIONS 2 5,c'f%Pn n ,11 f A ° [a EXPLOSIVES From to real below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE PIPE ❑MUSHROOM CAP 13 3 feel beiowsurface or ✓ feet bolow sudaco K>3 feet COMMENTS: '1 L^u.r t tr IT ,mow- W-t, w-z C-to.?.may, rw•.1� �,c!a.__!�w-7, I`�1J,' IVI L.UTS�G,(IJdk%k(L)L'1', C^W- 1f, [W''f� lJ �I IJ-2/I lU'?.LS,'V l/J-.j Ill Vt,7.3O, L/LJ-EIA VW-eN i 1 �\ r I hereby certify that I a auNlo Ized to complete this application and that the work will be done In accordance with Sa_n_Joaquin County-Or s e Codes and Standards,and all other applicable California laws. Signed -'^-"~ - --- Tfile/Company lJiCc r--�-" Print Nama CAA Data I l i J-I2C 7 G DEPARTMENT USE ONLY I I Application Accepted By: Data Issued: 1 l Z t Grout Inspection By/Dates: Destruction Inspection By/Dates: Facllil /Silo Information FANeme ,-` t.v(u r �c L FA Address FAN PRII 4 I 1 3 FA PE : j) WP Re*wed By Work Plan Da to ❑C57 ❑C57 AW1oda6al kc Other to Sign Pef61 ❑V&kefs Comp ❑Worke/s Comp W*er ❑Enuoxwent Permit O Access Agreement ❑lead AgencyApployal ❑MFR COMMENTSICONDITIONS: 70 �31��Lt_� [r YrS�L �� (,� I�ry �,�r '� � 1''l w y VIOL WP TYPE PE I SC I FEE INFO JAMT REMITTEDI CHECIUI I RECV'D BY I DATE I WELL PERMITtl INVOICEI! Parmi( S179 x `�� INPRU0146,1 1666 E.Hazelton Avenue i Stockton,Californla 95205 1 T 209 466-3420 1 F 209 464-0138 1 vrwW.sjcehd.corn Elio 29 01 07-01-202S SAo MiVgation Wel Permit AWjut;on