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e a AN JUAQUIN �if'tUtnes5 glows Flcf'i Environmental Health Department 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 andlor 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. 2575 Country Club Blvd. Stockton, CA 95204 Job Address y City/State/Zip Phone Cross street Plymouth Road APN 1.2302012 Property Owner* *Work on Caltrans Property, approved permit attached Phone Address C-57 Contractor _� Drilling Address 13124 Firestone Blvd City/State/Zip License# `140854 Phone (714) 994-0402 Citylstatelzip Santa Fe Springs , CA 90670 Consultant/Sub-Gontractor Wayne Perry,License# 300345 Phone 714-826-0352 Address 8281 Commonwealth Avenue CitylState/Zip Buena Park, CA 90621 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ❑ MONITORING ❑ ❑ EXTRACTION (Vaporf�Valer) ❑ ❑ SOIL VAPOR PROBE __ ❑ 0 SOIL BORING 3 ❑ INJECTION (Air Sparge, ozone) ❑ ❑ OTHER ❑ WELD SOIL BORING IDs INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA, OF BOREHOLE 2 . 5 0 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes [R No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE OTHER: GROUT SEAL PUMPED? ❑ Yes IR No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPEC]FICATIONS Neat cement, Qravity fed DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS El HOSE El PIPE COMMENTS: Signed f' Print Name 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 ❑ MUSHROOM CAP 1713 feet below surface or feet below surface if >3 feet I hereby certify that I am authorized to complete this application and that the work will be done in accordance with _ San Joa�qui�County Ordinance Codes and Standards, and alhDiher applicable California laws. / Title/Company 2, / 2 Lzz NA del � 07,&1r` Date Application Accepted By: Grout Inspection By/Dates: JEFFREY WONG Destruction Inspection By/Dates: Facility/Site Information 27 2022 Date Issued: FA Name confi tio� nurr�De�r #1 17��9$ SR0084I 80 1868 E. I-iazelton Avenue �toc ton, a Ifornla T 209 468-3420 464-0138 vv ov.or I I I F 209 ww.s 1g � /ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Applicati I=ormer Shell Service Station FA Address 2575 Count Club FA# �� PR# PR0544923 FA PE WP Reviewed By Jll Work Plan Date 2 21 (� C•57 ❑ C-57 Authorization for Other to Sign Permit ] Worker's Comp ElWorker's —114 Comp Waiver Encroachment Permit ElAccess Agreement Lead Agency Approval MFR COMMENTSICONDITIONS. Submit report to Note: permit is issued to Wayne Perry's EHD per SJC C-57, which Well Standards 13.7.2 MR Drilling will be working under. Caltran encroachment on file WP TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit 2905 1 313 $152x 3 456 cc 1/27/22 WP0042941 on