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SANJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> :,�, �;;" Greotness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 andfor install the work described. <br /> This application is made in compliance With San Joaquin County Development Tide,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 2to790 UANTA ROAD City/State/Zip .IfAc.) CA 9$304 Phone 911.hIg j-3Z 7a <br /> Cross Street WC-ST Li nj,JH RnAn A/� APN 0 2$•2^/ SD-o A'w.-oo <br /> Property Ownee 267oo 5. BAvtA LAID LLc.— Phone (9/6 )70 -3Z9L <br /> Address 921 377L- 54-rUri / City/State/zip cSAerAMFNro .f A �15�f10 <br /> C•57 Contractor R�1�nc£!l ri£ int✓. 1. f�b�• License# lO 0 37 b 5 PhoneC7.OQ 41,7- / 00'I <br /> Address al-7 6-Aa s.J AA, Ao City/State/Z(p 5jo ronrlc�A 9SZb)5 <br /> Consultant/Sub-Contractor AG,3- License# fOln 37bS EyQ-jiOZ Phone ZOq - 00\9 <br /> Address K17 $NAW RoAO City/State/ZIp3Tn.C.K')'an/ .U► 952)S <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: OUsite BodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELDSORING UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH Zol ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION plaporAValer) ❑ HAMMERMINVEN D61,OF BOREHOLE 1.5 '. hr, 0MULTIPLE CASINGS MULTFLEVELWELL CASING DMA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS VIA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 'g,SOLBORING PUSH POINT(GP/CPT) CONDUCTOR CASING 0 Yes FZNo Bodng Dist Casing D'N: -- Caslng Depth: — <br /> ❑ INJECTION LQsovue.om i O HANDAUGER GROUTSEALDEPTH 20A TRDAETYPETOBEUSED. GAUGERS OHOSE OPPE <br /> ❑ OTHER O OTHER GROUTSEAL PUMPED? — To XNo (Note:Maxhrem FMM Depth is 30 FQ VSL <br /> WEUfSOIL BORING IDs -Elo -1. ^L GROUTSPECIFICATWNS T E, <br /> A 2. n�_ rNo.,,O (If LEAC ­Jn 1;�11A• <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> OWELLS70 BE DESTROYED ❑OVER•BORE DIAMETER of_Nches(o depth of_feel <br /> WELL IDs ❑PRESSUREGROUT To depth of_feet below surface <br /> GROUTSPECIFICATIONS ❑EXPLOSIVES From—to—feat below surface <br /> TREMIE TYPETOSE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feetbelaysudace if>3 feel <br /> COMMENTS: 5z#.P)E> Sha) I bE A rJ qlT ato -�i rAX lrA I S AA70 VOC15 <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 77tMs rl. PA_. TillefCompany PQp�L t_r MA,1sl L// A r,1- <br /> Print Name l vL_. (,.J£11 A. Date 010 i Z.5 "% I <br /> EPARTMENT USE ONLY p <br /> Application Accepted By: -a Date Issued: 8 Z Z <br /> Grout Inspection By/Dates: --? <br /> Destruction Inspection By/Dates: `J Z <br /> FacilltviSite Information <br /> FAName 4 q FA Address I FA# 0 0 Z$ 1.0 2. 1 PR# D 4+B 9 9 Z <br /> FADE WP Reviewed By Vv lWorkPlanDate <br /> ❑CS7 ❑057AUhabalionforONerloSlgn Permit ❑Workers Camp ❑WakersCompWaiver ❑EnmadmenlPenil ❑AocessAgreemenl ❑LeadAgenryApproval OMFft <br /> COMMENTSICONDITIONS: 5 �tbW)r-E a- (p�lA 6�- O'r� J� ��C, �Q,I�,S�iA1 q•• <br /> to eHv <br /> WP TYPE PE I SC I FEE INFO JAMT REMITTED CHECK# RECWD BY I DATE WELL PERMIT# INVOICEN <br /> permit 2405 31 s,SZX k-g CC (rl2s W 24.000 S <br /> 1868 E. Hazelton Avenue I Stockktton.Califo nia 5 05 209 468-34201 F 209 464 01�� s)�hd com <br /> EHD 29A17M-2023 ere Midgalion Well Pemul Appragon <br />