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°F S A N.�10 A U I N <br /> Q Environmental Health Department <br /> Greatness ;roris here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> 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 /> 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 NB and SB shoulders of 1-5 from SR-4 interchange to Carlton Avenue City/State/Zip Stockton,CA Phone <br /> Cross Street 1-5SR-4 to Carlton Ave APN No APN,Caltrans ROW <br /> Property Owner*Caltrans Phone 209-471-7197 <br /> Address 1976 MILK Jr.Blvd City/State/Zip Stockton,CA,95205 <br /> C-57 Contractor Geocon Consultants,Inc. License# C57-716050-,t //A'Z t Phone 9/A <br /> Address 3160 Gold Valley Dr.Ste 800 City/State/Zip Rancho Cordova,CA 95742 <br /> Consultant/Sub-Contractor Address License# Phone <br /> City/StatelZip <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH Tic 15' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERORNEN DIA.OF BOREHOLE 2.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL.VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC❑OTHER <br /> ® SOIL BORING 40 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Oia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Spume,Ozone) ® HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE❑PIPE <br /> ❑ OTHER {a OTHER: Direct Push GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS eA=-- <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [-]AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> c�-ccor-da tr, �vr ��� t'l«��� �. ,>t« ` dtatnQ�) <br /> �����.�'�i�tete�r fa►� 1'min aft cilz�d f4'�omp,�Eia�-tfi#s applliratipn�I��4ha�tlt�w+olrkinrill,be dotti��;1L��cR�anitttx�'�'�� � ' <br /> '.-T_c .era``�' _-�>`��=�����.�:;�-�:8 .;lRe-yi►D C�tunt'' �v ,, , <br /> �,-_- >• -- - _ Hance{:nd���nd�lanfiaufi$,`_3an>a�tli_°nttter;Sappllcabte-Calitaii'niataws:" ._.x...:'��:<�::� ��--� <br /> Signed Title/Company �d/rl/: sl'/di1e�/YG�iQ ��/f!L} <br /> Print Name �17L ��r Date a.Z- aoa j <br /> S <br /> DEPARTMENT USE ONLY <br /> 2 f <br /> Application Accepted By: L Date Issued: <br /> 4 <br /> Grout Inspection By/Dates: € <br /> 3 <br /> Destruction Inspection By/Dates: t: <br /> Facilit /Site Information r t <br /> FA Name "(irf y f)U I-� m A Address -/{ I ,� Z c FA# 100 <br /> g CL� PR# 0 <br /> FA PE C C'} WP Reviewed By lWorkPlanDate <br /> Q C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval MFR )� <br /> COMMENTS/CONDITIONS: A t x rl 6 `. I_ b G <br /> s m s C <br /> WP TYPE PE LSC FEE INFO AMT REMITTEDI CHECK# RECV`D BY I DATE WELL PERMIT# INVOICE# <br /> Permit L L S t Z 1 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 J www.sjcehd.com <br /> EHD29-O'I04-20-23 CC A 1 L� �_ Site MiGpaUo�M0rmfllApplication 1 <br />