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AN JOAQUIN EnviY-onrnentai Health Department <br /> E— <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT 1 YEAR FROMDATE ISSUED <br /> 24 Hou',�: Advance Notice Required ,.,,1 ;,-IJI lnspscfio-i : <br /> CALL (209) 953-7697 For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development T-gle,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address CitylStaterZip ,t3 <br /> ne <br /> Cross Street APIN <br /> Property Owner' D-WAIA Al- Phone <br /> Address Ir- <br /> __fj — 3 <br /> C- CltylStatelZip <br /> C7 Contractor... ,.v e. License# Phone <br /> Address I City/State/tip <br /> Consul tant]SU b-Cpntra ctp —License# i ) <br /> Address j 1. - " IS- 7. �:, -- Phone <br /> L 4S City/Statelzip, <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Ofisite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE 0FMkLLjBo RING NUMBER W§L TAN A 1 TYPE j <br /> — _UA CONSTRUCTION SPFCfl(�Aj1QNS <br /> 0 MONITORING —0 HOLLOW STFLI BORING DEPTH 0 Wt.I LD TRAFFIC BOX 0 STOVE PIPE <br /> 0 EXTRACTION(VaptwAVi1f.r) 0 HAMMERORIVEN DIA.OF BOREHOLE 0 MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DNA0 SOIL VAPOR PROBE 0 MUD ROTARY CASING"IMICKNESS TYPE OF CASING: 0 STEa 0 PVC 0 OTHER <br /> SOIL BORING -=O PUSH POINT(GP/CPT) CONDUCTOR CASING 0 Yes 0 No'Boring Dia: _Casing LNa:___Cas"Depth: <br /> ❑ INJECTION LAESWq*__q,,.") Xi HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE C3 PIPE <br /> 0 OTHER OTHER GROUT SEAi.PLUPED? ❑0 Y-9 C3 No (Nde Maximum FreefdI Depth is 30 Ft) <br /> 'NFL LISOIL BORING IN GRGUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECK ALL I I IAT APPLY) <br /> #WELLS TO BE DESTROYED OVER-BORE DWAETER of_J�L inches to deoth c,.3 ��'O <br /> WELL lDs "j\ -L-T <br /> E]PP-PSSURE GROUT To depth of_fee,belmv surface i"11- <br /> GROUT SPECIFICATIONS 0 EXPLOSIVES From—to feet wm slw"c -3 L- <br /> TREMIE TYPE TO BE USED D AUGERSnHOSE C1 PIPE O(LA!CAP 0 3 feel below sur—face "'ket below surface if>3 feet <br /> or <br /> COMMENTS. <br /> 4C14 4//Z,/ /.,(,I"P/1 4 1w 3" 6 -' eAF4? <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> S Cou Ordinance Codes and Standards,and all other apptic f California laws. <br /> Signed <br /> -- -------- Title/Compaq <br /> an y <br /> Print Name 02 <br /> Date 2- 2 S" <br /> LEPARLf�- ENT USE ONLY <br /> Application Accepted By:. MAKC-41— Date Issued: s, <br /> Grout Inspection By/Dates- <br /> Destruction Inspection By/Dates: <br /> Farifity/Site Information <br /> P A 4-a--0- <br /> FA PE 2-W Z WP Reviewed By K4work Plan <br /> FAAdiir;j� Ewle L141-i <br /> FA Name IF,, ()&,L,ri-juvar <br /> P Re., <br /> -s ef <br /> --4�T -- <br /> 0C.57 0CWAu0vu,0m for 00ww Sign PmTM El Workers Canp 0 vYbft s carp Waim 0 Eimmwierit pemill 0 ktm Agv~ ❑Lead Agency Apmw ❑MFR <br /> COMMENTSICONDMONS: <br /> WP TYPE PIE Se —FEE two AMT REMITTED 5!Hi cmy I!TCV*D BY DATE WELL PERMITS <br /> #NVOICXN <br /> Permit x <br /> 1868 E- Hazelton Avenue Sto;;ktori, Ckilifornia 9152165 1 T 209 468-3420 1 F 209 4(5-d-0 138 j Vimv.si-et it com <br /> EM 20-010"1-"24 site wbotim weN P.Z,40= 2dw" <br /> q <br /> 7 <br />