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•,9E-�l � _ J �� iV '' ��ll�`��11'°��6�f��f►J`i{Ll�{ �r-`r�� i�`tr�� !I:�r� �:�;; I'�i ('� I �� �p`u'� GHQ u�[l�� a 11�� W�� ; ��'<<�'�dG`J � P� ��ll��`� �6�='��L,�c�� u��9 �c�r W�9�w and i:3oring� Used i r�r �o�tfia•tr�inan'c In�es><ic�a�ions and Cemedia•iion NON-REFUI�IDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED 4ti i'r�U6.id:B s-tt3IV'cXb'�+E:G I�di3�.lE:� 6C�t�1.136"�(: i'l36' i�id1 �s�1�s�.irt;%Yi.iid: 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 Nrith San Joaquin County Development Tftle, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address Cross Street 23565 South Santa Fe Road Property Owner= Henry P.oad Gustavo Guzman Address 36��r'4ee��ea 1{Vay=' C-57 Contractor V&W Drilling Address 1133 Blackhurst Drive Consultant/Sub-Contractor Condor Earth Address 188 Frank West Circle, Suite I City/5iate2ip Riverbank/CA/95307 APN 249-070-110 Phone Phone S City/StateiZip � Mode5to1GA/95355 License# C57 +/720904 Phone City/State2ip GaIt1CA/95632 License# PG (16795 CitylState/Zip Stocldon1CA195206 Phone (205) 550-1154 (209) 743-7743 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite f3oringsMlells Require Access Agreements or Encroachment Permits TYPE OF>r1fELUBORItfG tlUt.tBER IiISTALLATIOtt TYPE CONSTRUCTION SPECIFICATIONS ❑ L!G�;ITCR;ttiG ❑ HOLLGW StEPA BORING DEPTH ❑BOLTED TRAFFIC 60X ❑STOVE PIPE ❑ E�tTRACTIUhJ (Vap_n'rlaler) ❑ HA616tER/DRIVEN DIA. OF BOREHOLE ❑ L4ULTIPLE CASINGS ❑ PAULTI•LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ Fr1UD ROTARY CASING THICKNESS TYPE OF CASIPIG: ❑STEEL ❑PVC ❑OTHER ❑ SOIL 60RIF:G ❑ PUSH PORdT (GP! CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia- Casing Dia'. Casing Dc�lt>_ ❑ hlJECTION tA.irSnsrne oznnel ❑ HAPJD AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: _ GROUT SEAL PUdIPED? ❑Yes ❑ No (Note: hta>>mum Freefdl Depth is 30 Ft) I;rELU SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORfC TO BE PERFORMED: 1E WELLS TO BE DESTROYED 2 1NELL IDs tAW�. MW -5d GROUT SPECIFICATIONS Neat Cement TRE�,11E TYPE TO BE USED ❑AUGERS ❑HOSE Q PIPE COMMENTS: Explosives tall be placed belovvthe sanitary seal t depth. �'y DESTRUC T ION n1ETHOD: (CHEcI< ALL THAT' APPLYI ❑ OVER•BORE DIAt�1ETER of inches to depth of feel ❑ PRESSURE GROUT To depth of feet below+ surface EXPLOSIVES From 211 to d0 feet beiosv surface ❑ tv1USHR00M CAP ❑ 3 feel belo.v surface or feet bebvr surface if >3 feet ��- � r• rt alr►tit S 8a� hereby certify that I am authorized to complete this application and that tl�e work will be done in accordance with R --�� Joa ui unty Ordinance Codes and Standards, and all other applicable California laws. � �� Signed _�l� Title/Company Yom- �� Print Name � �,�,� � C�r7r � L L-� Date ��,� �� +� Grout Inspection BylDates: Destruction Inspection By/D Far•ility/Kitt Infnr�natinn r. • � - • FA..Jame `��Q,Y^ �(r � AAddress 235 � Sa� � FA# � � 'Z r> 3 � PR# (' � �� FA PE Zq � O WP Revievted By � � Work Plan Dale � �/g �� ❑ C•57 ❑�C57 Aulhoraalion for Other l0 5ign Permit ❑ We{kers Camp ❑ Wcrker s Camp Waiver ❑ Encroachment Permit ccess Agreement ead Agency Approvd MFR COM6IENTS/C`ONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTLED CHECI<#J RECV'D BY DATE PERMIT# INVOICE/# Pemlit �(% 3 1� $152 x � � � 3Q "1 1 � �6 !� Lj �� Z� 3 � SWELL V�/ GO�.�- � 6 Z© 18G3 E. Hazelion Avenue { Stocl.�ton, Caliral�nia 95?Oti { T 20J 468-3420 { F 209 4G4-0138 { ��n�W�r.sjcehd.com EHD 29-01 08-01-17 Site P:litlgation Nlell Permit AFpficatimi