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' ;r`° • :�°` '' SWJOAQUIN Environmental Health Department <br /> ltil : —COUNTY— <br /> Greatness grows hen. <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 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 267m South Banta Rd. C•r,�µy ) City/State/Zip Tracy/CAM53o4 Phone NA <br /> Cross Street w unne Rd. APP <br /> Property Owner* OIIn Coiporenon ` '1 R�12 ntst) Phone (4oe)5e9-0mo <br /> Address 3855 Nodh Ocoee SL,Suite 1100 CltylStatelZip ClevelandnNr37312 <br /> C-57 Contractor cascade License# 1058336 Phone (510)478-OM <br /> Address 120 S.23(d SL City/State/Zip RlchmondfCA194e04 <br /> Consultant/Sub-Contractor wood. License# PG10032 Phone (510)637-8057 <br /> Address 55512th Street Suite 215 City/StatelZip OaklandlCAM4607 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note'. Offsite BoringsNJells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL113ORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> W MONITORING 1 ® HOLLOW STEM BORING DEPTH 50feetbgs ❑BOLTEDTRAFFIC BOX El STOVEPIPE <br /> ❑ EXTRACTION(Vapor[Waler) ❑ HAMMERA)RIVEN DIA.OFBOREHOLE Bthches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS ASTM Sched So TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOILBOFJ14G ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ®No Boring Via: 8inches Casing Dia: 2 Inches Casing Depth: 0-48 feet bee <br /> ❑ INJEGHON(Aksoaae.0mne) ❑ HANDAUGER GROUTSEALDEPTH 3A0feetb9s TREMIETYPETO BE USE. ❑AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? 10Yes [I No (Note:Maximum Freefell Depth is 30 FQ <br /> WELUSOILBORINGIDs MW-17.See attached Wed<Plan fa I-11on. GROUT SPECIFICATIONS Neat cement(94 lb ba4f5-10 gal water) <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> If WELLS TO BE DESTROYED OVER-BORE DIAMETER of_ —inches to depth of_ _feet <br /> WELL IDs I PRESSUREGROUT Todepihof_ _feel below surface <br /> GROUT SPECIFICATIONS rater) ❑ EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE UStU LJ AUUtnb ullUSE ® PIPE ❑ MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel <br /> COMMENTS: D v r _ /) r .f� F�• 6N P�R. R /1-5-1w ZL <br /> -C'II hereby l y�certiTefy`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 Qa -.eae�rP2¢cz!an- Title/Company Weod. <br /> Print Name Jag.Reeder Date aen2 <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By: 4 20 22 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facillt /Site Information <br /> FA Name �• r nf\ FA Address Z. FA# d 0 j PR# p <br /> FA PE 2A 6 Q WP Reviewed By Work Plan Date Z OZ2 <br /> ❑CST C-57Aulhodzellon for Other to Sign Permit ❑Workers Gomp ❑Workers CompWalver ❑Enaoachment Permlt ❑Access Agreement eadAgencyAppnwal PAR <br /> COMMENTSrIC9 ejNDITIONS: �.L Q- copy ,,F �,,,�f St� <br /> PJA V Re "&; l I `". l GtLLL°SS <br /> � r� On Si{� burr �O,e (OL werk , 71u cery , n !!¢ �wor(`-' aH <br /> :s root S ' <br /> WP TYPE PE SC FEE INFO AMT REMiTTED1 CHECK# I RECV'D BY DATE WELLPERMI%:T INVOICE# <br /> Peril Aot 1313 s I I ee I irfVVIV1171AWFOOV� b� 1 <br /> 1p <br /> 1868 E. Hazelton Avenue�Stookton, Califo, in a 95�0� TT 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 04-04-07 Site Mitigation Well Pe"t Application <br />