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SAN JOAQUIN <br /> _ 11 ".— , <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 1607 Turnpike Road (right-of-way,wells) City/State/Zip Stockton,CA Phone (209)4664601 <br /> Cross Street South Lincoln Street APN 165-040.040-000 <br /> Property Owml Dustin and Kristen Saccone Phan. (209)940-7114 <br /> Address P.O.Box 710 City/State/Zip Stockton,CA,95201 <br /> C-57 Contractor AdvancedGeo,Inc. License# 1063765 Phone (209)467-1006 <br /> Address 637 Shaw Road City/State/Zip Stockton,CA 95215 <br /> ConsultantfSub-Contractor Slagle Drilling Corporation License# 1046151 Phone (916)363-9355 <br /> Address 11345 Trade Center Drive City/State/Zip Rancho Cordova,CA 95742 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes [I No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(AIrScree.O w ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Fmelal Depth Is 30 Fit <br /> WELD SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED One(1) ID OVER-BOREDIAMETER of 4 inches to depth of 49 feet <br /> WELL IDs MW-5 ❑PRESSUREGROUT To depth of`feet below at <br /> GROUT SPECIFICATIONS Portland type 11 cement l0 surface grade El EXPLOSIVES Fran—to— feelbelowsurface <br /> TREMIE TYPE TO BE USED [ AUGERS ❑HOSE ❑PIPE E]MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: MWSWII he overdNlm tu49feetbag using 88¢haugem. <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed All Title/Company Staff Scientist AdvancedGeo, Inc. <br /> Print Name yl� ie Kucerax Date 28 October 2022 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57Authonzation far Other to Sign Permit ❑Workers Comp ❑Workees Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE I SC FEE INFO AMT REMITTED1 CHECK#I RECV-D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 Www-sjcehd.com <br /> EHD 29-0104-04-07 Site Mitigation Well Pemit Application <br />