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SA NUJ OAQ U I N Environmental Health Department COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT AP 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 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 Address -47C-S. ImfIyIce ep fyc- City/State/Zip .S7dC&MN r,4 9S.Z/$—Phone (A'07) 993 3S-S-7 Cross Street /J,t-felpdr,¢ Rb APN t7IS3'012 Property Owner" /tL T HOLPhone (Z0) 993- 3537 Address 379r 1IL&V,roRb AVjF� City/State/Zip SAN C 94-,Z/5 C-57 Contractor 11�oX 4wlwlS //✓C License# 37ZZ3/y Phone �/6,3t3 -a./yv' Address 69&41 IV c eOM8M 9'7- City/State/Zip cSIfC/q/}J1AE/VYD rit 9sa Consultant/Sub-Contractor WR /ye/y/L,L11N/jW(L &MVICEt License# 9-C4-02.7-33-7k- 02=9 Phone 9/6 76/- 5-XZY Address ZOO-7 OLD FIHLA4 RP City/State/Zip &fkERCr/EL 0 CA- 93312- CONSTRUCTION 33/2CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ 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 O PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS 2 7SS DESTRUCTION WORK TO BE PERFORMED: 312u I 2�� 9 ''DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 2&vi �OVER-BORE DIAMETER of inches to depth of feet WELL IDs SEE 477,41Cy6b As,SM\,AtA [►PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS C T—(KEXPLOSIVES FroJ, to ,feeett below surface TREMIE TYPE TO BF USFn [:]AUGERS ❑HOSE FRPIPE 1 Zv`'LL [.MUSHROOM CAP ®'3 feet below surfac-e5f"� feet below surface if>3 feet COMMENTS: - -r v1 w� CJS �-111 7 < L Z J M S C , F-,ULL 1 hereby certify that v-, S- .....,....r._.s urrs appdcatiion and that th"ork will be done in accordance with Joaquin County Ordinance Codes and Standards,and all other applicable California laws. TS Signed Title/Company &-rr1A 117YJ/Q FbIC LOOM/C 1z;WC. Print Name CrLV,� AVR&Z 6 tF Date 9/6 Axs- ti DEPARTMENT USE ONLY j Application Accepted By: �� Date Issued: Grout Inspection By/Dates: Dyi 3165 'pu(m 1 ht'= jA),A.j:a 601AM VIi b Y 108 ft 14 Ywk -NOT O eSt,rO M W� vFA Destruction Inspection By/Dates: mu n=In cab 17�s 4 ■ ,Tr�v�ea�e� l��A��fir. ti�v�ru w�S v>,o� fou Facili /Site Information s s alYcatil � FA Name lGta t L 7 f FA Address e q 6� I 7� v, � FA# L) 2 �Z3 PR# C, Wts(1C FA PE 2 C1 �l7 WP Reviewed ByIr NY). Work Plan Date Z 57 [DC-57 Authorization for Other to Sign Permit lVvorker's Comp ❑Workers C p Waiver ❑Encroachment Permit Access AgreementLead Agency Approval gMFR COMMENTS/CONDITIONS: ` ��) W��v- S('Lac 1.1 �- {';rv>�g�^r�7 Co,.,,�-a.t v,,�u-✓T�,��} 5 �-(>�n-<-� �- 715,�S.L� WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PE/R�MIT# d INVOICE# Permit Zc /13 $172x U t -?? � o Z� t n'1 f a 5�0 5 54 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 Site Mitigation Well Permit Application