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S A N 10 A Q U I N Environmental Health Department <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 near 953 Adelbert Ave. city/state/zip Stockton, CA 95215 Phone <br /> Cross street East Main Street APN <br /> Property Owner* San Joaquin County Public Works (San Joaquin County ROW) Phone 209-937-8444 <br /> Address 425 N. El Dorado Street city/State/Zip Stockton. CA 95202 <br /> C-57 Contractor MR Drilling License# 740854 Phone 714-994-0402 <br /> Address 13124 Firestone Blvd city/state2lp Santa Fe Springs, CA 90670 <br /> Consultant/Sub-Contractor Atlas Technical License# Phone 209-579-2221 <br /> Address 1117 Lone Palm Ave., Ste. 201 B city/State/zip Modesto, CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLBORPIG NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION thaw/water) ❑ HAMMERIDRNEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(Opt CPT) CONDUCTOR CASING ❑Yes ❑No Bairp oia: Casing Oia: Casing Depth: <br /> ❑ INJECTION imrsoaoe.Ozonel ❑ HAND AUGER GROUTSEALDEPTH TREME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nale:M"mum Freelal Depth is 30 FI) <br /> WELD SOIL BORING Ds GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DOTRUCTION METHOD:(CHECK ALL THAT APPLY ( <br /> #WELLS TO BE DESTROYED 3 VER-BORE DIAMETER of Inches to depth of feet <br /> WELuos MW13A., Ss R€sRBLIT Todepthof 11i feelbebwsudace <br /> GROUT SPECIFICATIONS Neat cement ❑EXPLOSIVES From to_feet below surface d <br /> TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑PIPE ®MUSHROOM CAP ®3feelbelowsuch mot feel below sudace if feet dl- ly <br /> COMMENTS: !� <br /> �° V ej <br /> }Mast' -Prr Z/Z.lr zZ <br /> 1 hereby certify that I am authorised to complete this application and lhei the work will be don n a cordance with 1, <br /> San JJooaagquuuiin County Ordinance Codes and Standards,and all other appli ab California laws. `"-{^-• <br /> Signed — Title/Company prl;S;dP, �S�-N 0rilliii A R�,1A <br /> Print Name�`�� 1ole'r Date It�.e�Da.l <br /> /�/I EPARTMENT USE ONLY <br /> Application Accepted By: ZI Date Issued: <br /> Grout Inspection By/Dates: _ n ^ /�t�� i /. 1vn`"r/LS <br /> Destruction Inspection By/Dates: 64� �—24`1a 2 Q klw-I <br /> Facilit /Site Information 4 '" — i c�'���- �CL Z S <br /> FA Name A ��G FAAddress 0 �� FAA PR71 _.S�j) <br /> FA PE 2 WP Reviewed By Work Plan Date g q 2 If <br /> 2 <br /> 7 ❑C57 Authatratlon for Other to Sign Permit ❑wwws carp ❑woikds camp waiver ❑Encroachment Permit ❑Access Atimmenl ead AgencyApproval FR <br /> COMM <br /> TS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D Y DATEWOO2 <br /> MIT# INVOICE# <br /> Permit ZgOZ 313 $152X Lt 5(7 007W r 5q <br /> 1os4bsz <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 468-3420 i F 209 464-0138 i www.sjgov.org/ehd <br /> EHD 2MI 06-2e-21 Site Mitigation Wei Permit Appiretion <br />