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1 le 1 SANJUQQUIN Environmental Health ®epartlmont —COUNTY— SITE MITIGATION WELL & GORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AT Zoo 0 $,j LF) 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Applicadon Is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application Is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the �eoSan 9Joaquin County Well Standards. Job Address � City/State/ZIP 66Crj^y(A b Phone Cross Street r APN ^1'7 Z6G0N Property Owner' ('/j Phone Address �/ City/State/Zip C-57 Contractor 1 ( % License# q0 B Phone Address SL 5�� city/state/Zip (Z u Consultant/Sub-Contractor ,,1 License# N Phone . b-26 /-1�12� Address _�D�lti�t< WA nix 54nf' Clly/StatelZlp I ^( /7 ��7 L/ 1 CONSTRUCTION WORK TO BE PERFORMED:*Note: O#sHe Borings/Wells Require Access Agreements or Encroachment Permits TmYrPE OF WELUBORING UMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS W MONITORING (] HOLLONSTEM BORINGDEPTH ❑BOLTEOTRAFFICBOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/WaW) O WIMMERIDRIVEN DIA OF BOREHOLE 6 ❑MULTIPLE WINGS❑MULTI-LEVEL WELL MING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASI ❑STEEL 6rPVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING �SQrrrTTT'Yes 0No BMIp Dig; 6 Caging Dig: 11 Casing Depth; ! ❑ INJECTION IM4weeomnel ❑ HANDAUGER GROUT SEAL DEPTH 361 TNEMIETYPETOBEUSED ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER C9 OTHER oni6 GROUTSEALPUMPEO7 OY ❑No (Nde;MadmumFreetaADapNis30Fq WELI/SgLBORINGIDs - I - W GROUTSPECIFICAnONS ✓ gjJrt'a .S¢ 011-0 W 111W-LA( it,. 1ile4± AA C. 6 r f \ D Pea DESTRUCTION WORK11 BEPEfRFORMED: DEBT }I NMETH &A cKAUTHATAPPLY1w 5 ) fr �' If WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of__inches to depth of_feet -�`�5�� P WELL IDs ❑PRESSUREGROUT Todepth of_,feet below surface `^w+J GROUT SPECIFICATIONS [I EXPLOSIVES From to weat feet below surface .11P imp TREMIETYPETOBE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet lleslp COMMENTS: ,� S r�er: Cno 441,e /7- I o (A), �` ^� 'jiJ 5 41tek / I hereby certify that I am authorized to complete this application an Y the work will be done In accordance with � lk3 It. i San Joaquin County Ordinance Codes and Standards,and all other ap�llicable Califomla laws. �l- - o-f- W N Stnrtdq Signed Tille/Company Y,Od(or /VI4hAfh- L WrC 1��Ilin� Print Name OlViv r6L✓l Date TZq- Ztf —BEPARTMtNT USE ONLY �I Application Accepted By: (rJ —� Date Issued: /-7-- 2D L l Grout Inspection By/Dates: GJ Destruction Inspection By/Dates: acitit /Site Informalio FA Name IiG FAAddress 'LOOip IMS 6f, FA# PR# FA PE 2q 1J N � WP Reviewed By W Work Plan Dale a rSDySJ xi (7 2L 7 ❑G57Autherhagon(wOth.to nPe I ❑Woikefs Comp ❑Wodcefscomp Wa sntftnik ❑AIceI Agreement ead AgemyAppmyal FR - Ct'OQMENTS/CONDITIONS_-( �y,P,a;.t Rm0 Co Vtrs u+.iy 5 !\DYYY 4Ay .t-;Aa.� abeam TS lt(l�, C {b percarz uJt�l gMlt4'E Did. jy CmylekfEM4 WkaA Ao JN9Pr In LLrVICe Lklg rSefb.OJL y ( rj2Qr--j TY WP PE pPE SC FEE INFO AMT REMITTED CHgECK# RECV'DD _BY DATE WELL /'PERMIT# INVOICE# Permit 2901 c313 �X $fob CC. ZOZ W P Y-DD I 3 GL I gy—i F 1 e S2 ? F 0-0. 3-�'L 1868 E. Hazelton Avenue I Stockt n, California 95205 T 209 468-3420 I 2 4 4-0138 I wwws)cehd.com EHD2B-0r 7-0t-2013. � �p., w� ik � '�'�Qp��/ ( Vie MiI19aaon Wen PonnitApptWon I