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SKJOAQUIN Environmental Health Department <br /> —COUNTY— 9(-V6Q -- <br /> Grcotness grows here. J / I+ PC <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All 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 /> 95205, 4$1$ <br /> Job Address Gkotao I- , M.4ln c}1{�e}- Cily/State2 G 1p STA 7a C Phone Z09 -r}t3- <br /> Cross Street MA,,f% S L,rr S ¢ Ir APN 5 ^ as G -1tF o <br /> Property Owner' Anciri UAo MEot"t:A/11 XFVorVE We5T '-)O 4L-91C7 oIJr. Phone S28' ^ $'97 "14 7 <br /> Address ­7515 Sov TIA Fa <br /> -�^oa � 1Ge A o City/State2lp R L^;vf ^Aeo/!t Y CA 94$So <br /> C•57 Contractor A d vAnc>: LTFo License# 140 617 b 5 Phone Z at) - 467 ^10 b <br /> Addressy- 77 S'IAAW AonL Ry/stalealp 5'ToCkTD,/ �} 95a1S <br /> ConsultantiSub-Contractor AAVA oc kDGFn .-I-ne, _ CA6-jense# 1 (3lQ 745 Phone 201 ^y y")- PQ b <br /> 7 I Address '7 5 8� }-l�Ao City/State/Zip SToc.r ,, .z A-A 95QS <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: ONske BodngslWells Require Amass Agreements or Encroachment Permits <br /> TYPE OF WELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BOmNG DEPTH ❑BOLTEDTRAFFICBOX ❑MOVE PIPE <br /> ❑ EXTRACTION(VapeOWstet) ❑ HAMMERmRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORINO ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes [I No Baing Dix: Casing Its: Casing Depth: <br /> ❑ INJECTION(Aksome.otakl ❑ WIND AUGER GROUTSEAL DEPTH TREMIETYPETO BE USED: GAUGERS ❑HOSE ❑PPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Nola:Ma)mun FteefaB Depth Is30 FU <br /> WELL/SOIL BORING IOs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD, (CHECK ALL THAT APPLY) <br /> #WELLS TO 13EDESTROYED VOVERBORE DIAMETER of��inches to depth of (�Qfeet <br /> WELLIDs Nk LJPRESSUREGROUT .To depth of_feet below solace <br /> GROUT SPECIFICATIONS ur"L NO 1 [I EXPLOSIVES From ID_feelbelowsudaw <br /> TREMIE TYPE TO BE USED El AUGERS [I HOSE 3KPIPLI ❑MUSHROOM CAP ❑3 feet belowsudace or feel below surface if>3 feel <br /> COMMENTS: 5-F IZ %,J/o i`K f IA rJ V Pr\ F O p 51 1;3 4) Los ZO <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> Be County County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Q t I IA Title/Company SsN e0 8 P ' , <br /> Print Name TjM O'f v �V £ I I.A.2 Date ns f1 OBI to <br /> DEP RTMENT USE ONLY <br /> Application Accepted By: Date Issued: L=h, 2-0 <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Factli Slte Informationl <br /> FA Name (cam µ4 AAddress D a� FA# U O O PR# ✓✓✓0 -14 <br /> FA PE 2 P Reviewed By /f ork Plan Date /q D <br /> Cb1 0057Au11nrka6anforOflwto Sign Permi ❑Wakefs Cone ❑Wetketscorvftrer_c❑l EnerssaunmlPamB ❑AaessA9rownt 0Le9dPgergAW*"1 ❑MFR <br /> COMMENTS/CONDITIONS: 54 W7 I r-6 S -(­o P "lid 13 z <br /> JWPTYPEJ PE I SC I FEE INFO JAMT REmTTTEDj CHECK# I RECV'D 9Y DATE WELL PERMIIT# I INVOICE# <br /> Permit v%Z 31 152x Z I C. C. 10 w VO4'l7 7-`151 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> Elm 2941 OBa1.17 Ske MflW9on Well Penn%AppioeVon <br />