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SAN JOAQUIN Environmental Health Department <br /> .�L <br /> —COUNTY-- <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> _—NON-REF NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours dvance Notice Required For All Inspections <br /> ALL (209) 953-7697 For INSPECTIONS <br /> App tiewl ereby 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 639 West Clay Street City/StatelZlp StocktonlCA/95206 Phone <br /> Cross Street Harrison Street&Jackson Street APN 147-071-100-000 <br /> Property Owner' DSS Company Corp Phone 209-948-0302 <br /> Address 655 W Clay Street City/State/Zip Stockton/CA/95206 IIyy <br /> C-57 Contractor AdvancedGeo, Inc. License# 1063765 Siff -Z- Z EV'4 hone (800) 511-9300 <br /> Address <br /> 837 Shaw Road cilyistate/Zip Stockton/CA/95215 <br /> Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone (800)511-9300 <br /> Address Same as above. CitylState/Zip Same as above. <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BodngsANells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING LiHOLLOW STEM BORING DEPTH 15 feet ElBOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapor6Valer) ❑ HAMMERAIRIVEN DIA.OF BOREHOLE 1.25 inches ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> 21 SOILBORING 4 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes Cl No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(asoarae oiaml ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE <br /> Cl OTHER [IOTHER: GROUT SEAL PUMPED? El Yes ❑No (Note:Maumum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDS B22-B25 GROUT SPECIFICATIONS Cement <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 feel <br /> WELL IDs ❑PRESSURE GROUT To depth of feetbelow surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE <br /> /❑PIPE ❑ MUSHROOM CAP ❑3 feet below surface or feelbel surface if>3 feel <br /> COMMENTS: IIJCY p( Ta.'�—S ri r. j�Q r i!zt i o-rt � � �t,l O t.J CS <br /> P� , r n s C-� aW r1 ac�dart ce , <br /> I 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 /> Title/Company AdvancedGeo, Inc. <br /> Signed O9/20I2023 <br /> Print Name Jasle Singh Date <br /> EPARTMENT USE ONLY 'D /� <br /> Application Accepted By: Date Issued: F- <br /> Grout Inspection By/Dates: <br /> Destruction Inspection BylDates <br /> Facilit ISite Information ' FA � 2_ / — 5q-zU <br /> FA Name G FA Address ,3 �.q+�- k # Y PR# 0 I <br /> FA PE 7,6tWP Reviewed By Work Plan Dale zQ <br /> 57 0G-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Aocess Agreement ad AgencyApprovet MFR <br /> COM ENTS/CONDITIONS: <br /> /ee <br /> WP TYPE PE SC FEE INFO AMT REEMITTED CHECK# RECV'D B DATE WELI PER M_1 1 it p INVOICE# <br /> Permit O $ G�x (/ 10, 3 7i VV od it q, <br /> � `� 5 <br /> 1868 E. Hazelton Avenue I Stockton, California 9i 5 I T 209 46 -3420 1 F 209 464-011338a1enwwww sjceeen Perrot P d.com <br /> site EHD 29-0104-0407 <br />