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SAN JOAQUIN Environmental Health Department COUNTY— grows hrrr. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application 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 San Joaquin County Well Standards. Job Address 26700Somh Banta Rd. City/State/Zip Tracy/CA/95304 Phone NA Cross Street W U.Rd. APN 25201" Property Owner* olincorporalion Phone (408)599A0W Address 3e5514onh Ocoee St,Suite 1100 City/StatelZip Cleveland WJ7312 C-57 Contractor Cascade License# 1058m Phone (510)478-0858 Address 120 S.23rd St City/State/Zip Richm GVCA&1804 ConsultantlSub-Contractor Wood. License# PG10032 Phone (510)637-0057 Address 555121h Street,Suite 215 City/State/Zip Oakland/CA/94807 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BodngsAvVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXURACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Die: Casing Die: Casing Depth: ❑ INJECTION Wspaw,.Omne1 ❑ HANDAUGER GROUTSEALDEPTH 335feetbgs TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Fmefall Depth is 30 Ft) WEW SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 4 ®OVER-BORE DIAMETER of 20 inches to depth of 3 feet /,y I WELL IDs MW-01. loc,MW-7,MW-ie.See aItaMed Wak Plan fm ations. �spa To depth of 3-2orz5re0 feel below surface ry hells �C ( .��w�`��/� GROUT SPECIFICATIONS Nesteement(94lbba9/5Egalwater) El EXPLOSIVES From to_feelbelowsuriace0A were— THEMETYPE TO BE USED ❑AUGERS ❑ HOSE ® PIPE El MUSHROOM CAP ❑3 feel below surface or feethelax sari ce if>3 feet COMMENTS: of r by 20 ZZ ll2ralr�lleo� no E 1\QSs wre ro o poSU2 +to SEt-f/M 'f0 4 40- r4tr" Wa I hereby cerUN that I am author d to complete this application and that the work will be done in accordance with jJ 4R h. �1 � San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed giw�� d,. Title/Company Vvood. Print Name f.a.Reeder Date B/3r22 DEPARTMENT USE ONLY / � ^ Application Accepted By: Date Issued: b p w Grout Inspection By/Dates: Destruction Inspection ByID s: Facilit /Site Information FA Name 10 -r- FAAddress I Z O aM FA# Ob I ' i PR# 0 Q FA PE WP Reviewed By --I VJ Work Plan Date vzrleo(z 0G-57 G57Auhdnnllw for Other to Sign Permit ❑Worker's Comp ❑Woders Comp Waiver ❑Encroachment Permit ❑Access Agreement ad Agency Approval MFR COMWENTSI ITIONS: WP TYPE PE I SC FEE FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMI E#ITT# INVOIC 9 Permit 02,1313 $1 Z I C1: Z yv 4 J At 1 49 y 3 4-3 1868 E. Hazelton Avenue I Stockton, California 95 05 1 T 2094fi8-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29 01 04-04-07 Site Mitigation Well Pernst Application