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• -9 °-°, SAN JOAQUIN p z ,, � Environmental Health Department LLJi hk —COUNTY-- - °d�rronN`�� Greatrlcs,. y,o :s hcri. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9,4 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 Addresslnnu 23915 6as� Mri4y, Rd City/State/Zip trindtn , CA. 9523 6 Phone (Zrq)B$4 -%Sao Cross Street N. Free- y.oacl I 10/ 12/2021 APN oqg -Ito -oSd -coo COMM ENTSICONDITIONS: SUMBIT A COPY OF REPORT TO EHD PER WELL STANDARS 13.7.2 Property Owner" A`ulylrvro,'FavMC6 CVuRerr 01hk. t jtnC. (Z5G) -SGU - ZS+'f$ Phone (Z51,)353 - 6843 Address l21 Sovvlervlll{ R.d tJ 6 , 1�e LakuY , AL City/State/Zip l�, Ccg.+ur-, AL 3566 C-57 Contractor ICe„h �Iltlgtowsy- , "V_ lf%vr IIInq License# -qyob Sq Phone (i!V) `1`/y -oe/oz Address 1312 131vd J & H Drill City/State/zip San,}.n t. SpvinaS, CA 90(0'+0 Cons uItant/SUb•COntractor Ma -l -f Liyihp-on License# 90662 Phone (`IZS�ku4 1$Sy Address 2rJOl C.ruw tranvnn Qct Su.I4C 210 r� CitylStatelZip Sah Qamor► CA . CONSTRUCTION WORK TO BE PERFORMED: "Note. Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH is kk - ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE Z . ZS �k ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER * SOIL BORING 3 ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge. Ozone? ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER 0 OTHER:jW r ZX- GROUT SEAL PUMPED? ❑ Yes El No (Note: Maximum Freefall Depth Is 30 Ft) WELL/ SOIL BORING IDs $13 1 r $ B 2 r $ e 3 7� GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [-]AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done In accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws.ATLAS t Signed %�% � �` Title/Company t?ro jeL-� (7�euio!aos . I A TL A S Print Name Michell -ie o-bii Date IU 1 14 1 2021 DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued: 10/22/2021 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name BONNIES PLANTS FAAddress 1 23975E MILTON TK FA002682� 1PR# PRO>472>3 FA PE 2950 WP Reviewed By J W Work Plan Date I 10/ 12/2021 ❑ C-57 til C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval MFR COMM ENTSICONDITIONS: SUMBIT A COPY OF REPORT TO EHD PER WELL STANDARS 13.7.2 WP TYPE I PE I SC FEE INFO AMT REMITTED CHECK# I RECV-D BY I DATE I WELL PERMIT# INVOICE# Permit 2905 )13 $152x 3 1 456 350 1 JW 1 10/15/21 WP0042696 SR0084 390 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application