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SAN J OA Q U I N Environmental Health Department <br />I' I --COUNTY— 4 <br />z3 yd <br />rt, Grr I i mess (IT/ tv.: hen'- <br />_ SITE MITIGATION WELL & BORING PERMIT APPLICATION off- J <br />,t �, 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 />" �a .> <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 930 East Dr. Martin Luther King Blvd City/State/Zip Stockton, CA 95206 Phone 714-589-7475 <br />CFO55 Street Aurora Street South <br />Property Owner' All Minl Vans & Minl Trucks Auto PTP <br />APN 167-183-030-000 <br />Address same asabove <br />C-57 Contractor Advancedceo, Ina <br />Address 937 Shaw Road <br />Consultant/Sub-Contractor same as C-57 contractor <br />Address <br />City/State/Zip sa as above <br />License# 106 <br />3735 <br />Phone zcsa67-tool <br />City/State/Zip Stockton, CA 95215 <br />License# 1063735 Phone 209-467-1006 <br />City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />930 E DR MARTIN LUTHER KIN <br />❑ <br />MONITORING <br />❑ <br />HOLLOW STEM <br />BORING DEPTH 15-2a feet <br />❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ <br />EXTRACTION(Vapor/Water) <br />❑ <br />HAMMERIDRIVEN <br />DIA.OFBOREHOLE 1.6inches <br />❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />❑ <br />SOILVAPORPROBE <br />❑ <br />MUDROTARY <br />CASINGTHICKNESS <br />TYPE OF CASING: El STEEL ❑PVC ❑ OTHER <br />10 <br />SOILBOWNG 5 <br />1Z <br />PUSH POINT (GPI CPT) <br />CONDUCTORCASING ❑Yes [I No <br />Boring Dia: Casing Dia: Casing Depth: <br />❑ <br />INJECTION (An Sparge. own al <br />❑ <br />HANDAUGER <br />GROUT SEAL DEPTH <br />TREMIE TYPE TO BE USED: ❑AUGERS El HOSE ❑PIPE <br />❑ <br />OTHER <br />❑ <br />OTHER: <br />GROUT SEAL PUMPED? ❑Yes [I No <br />(Note: Madmum Freefall Depth is 30 Ft) <br />WEW <br />SOIL BORING IDs set mrough SB5 <br />2903 <br />1 3131$152X <br />GROUT SPECIFICATIONS <br />NEAT <br />1 456 <br />CEMENT; <br />I JW <br />1 <br />12/30/21 <br />1 WP0042876 <br />TREMMIE <br />IF WATER <br />IS ENCOUNTERED <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />Signed_s <br />Print Name Evan smmmt <br />Application Accepted By <br />DESTRUCTION METHOD: (CHECKALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of_ inches to depth of _feet <br />❑PRESSUREGROUT To depth of feet below surface <br />❑EXPLOSIVES From to feet below surface <br />to 20 feet be <br />Title/Company stare ceotog sL Advancedceo, Ins. <br />nate Decamber vm. zozl <br />DEPARTMENT USE ONLY <br />ssued: <br />Grout Inspection By/Dates: � <br />Destruction Inspection By/Dates: <br />Facilit /Site Information <br />I <br />JEFFREY WONG 1 /3/2022 <br />FA Name <br />CONFIRMATION It <br />ALL MINI vnus s MINI TRucl<s Auro <br />FA Address <br />930 E DR MARTIN LUTHER KIN <br />FA# <br />FA0024463 <br />PR# <br />PR0542541 <br />FA PE, <br />2950 <br />WP Reviewed By <br />Jpy <br />Work Pian Dale <br />1 212 7/2 0 21 <br />BJC-57 <br />❑C57Authorizagonfor Other toSign Permit <br />❑WorkeesComp ❑ Workers Comp Waiver ❑Encroachment <br />Permit ❑Access Agreement ❑ Lead Agency Approval [NMFR <br />COMMENTS/CONDITIONS: SUBMIT COPY OF REPORT/RESULTS TO EHD per <br />SJC WELL STANDARDS 13.7.2 <br />WP TYPE <br />I <br />PE <br />I SC <br />I FEE INFO <br />JAMT REMITTED <br />CHECK# <br />I RECV'D BY <br />I <br />DATE <br />I WELL PERMIT# <br />INVOICE# <br />Permit <br />2903 <br />1 3131$152X <br />3 <br />1 456 <br />1 CC <br />I JW <br />1 <br />12/30/21 <br />1 WP0042876 <br />136561831 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 <br />SR0084680 <br />F 209 464-0138 1 www.sjgov.orglehd <br />EHD 29-01 06-28-21 <br />site Mitigation Well Permit Applicau'gn <br />