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S A KJ OA H I N Environmental Health Department <br /> a COUNTY <br /> "���,' G�eorness grows ��ere. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CAT Zito o SS`F) <br /> 24 Hours Advance Notice Required For All Inspections <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 Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address IMO � n City/State/Zip ��n "l'SZVh Phone <br /> Cross Street ffiT APN 11? 2.6(2 y <br /> Property Owner" r rn Phone <br /> Address City/State/Zip <br /> C-57 Contractor �We, Dr i,111'n a License# qc)69qcf Phone 63o-6&- � <br /> Address City/State/Zip 76 <br /> Consultant/Sub-Contractor (il <br /> l „ License# Phone <br /> lZ6y_ <br /> Address City/State/ZipSob <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ;K MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ( r ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ 90I-MUD ROTARY CASING THICKNESS TYPE OF CASING' ❑STEEL PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING Yes ❑No Boring Dia: f�_Casing Dia: 1_ z 1 Casing Depth: 61-11_ <br /> ❑ INJECTION(Air Searge.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER l9 OTHER: n G GROUT SEAL PUMPED? ❑Yp ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs - ( W GROUT SPECIFICATIONS (�[(rilaP _ <br /> t1t--h <br /> '1W-I a lytW-11, W-I � '� <br /> DESTRUCTION WORK >`O BE P�RFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) ' ` <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet r��s <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface nr+c- �'1wrtt, <br /> TREMIE TYPE TO BE USED [I AUGERS [I HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet�� �(�G <br /> COMMENTS: <br /> A ;ter <br /> I hereby certify that I am authorized to complete this application an -that the work will be done in accordance with t ►1. 1 <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company �/0 Gr 41')ti ll 811C l,vrt ��1 f in <br /> Print Name l3U/f CV ore(,,I Date 7"Zq-Zt( <br /> DEPARTMENT USE ONLY <br /> y <br /> Application Accepted By: ��� '��'� kj r Date Issued: Z- <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address e FA# PR# <br /> FA PE WP Reviewed BY Work Plan Date11 <br /> gp-57 ❑C-57 Authorization for Other to Sign Pennd ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement El Lead Agency Approval ❑MFR <br /> COMM ENTS/CONDITIONS;"fhr� t%+t �:d atrrl0wi COV ✓S vrly �ft <br /> ukyv��ttted �►'�I� J� Co>►�(e�12 o W Ao , in Sf" C e kncLr Q NI�(- F-k r <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# <br /> Permit vWW143 <br /> .V <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 w.sjcehd.com <br /> EHD 29-01 7-01-2023 A r�Kr/�� ,,�V�.`yy�� ! ;i,��rb y�.�— �, T wwSite Mitigation Wall Permit Application�A <br />