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SAN JOAQUIN Environmental Health Department <br /> --COUNTY <br /> Grec-,tness grows 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 1015 West Hammer Lane City/State/Zip Stockton, CA 95209 Phone <br /> Cross Street Thorton Road APN 07523039 <br /> Property Owner* Frank Jaworski Phone <br /> Address 578 Eastman Dr City/State/Zip Bigfork, MT, 59911 <br /> C-57 Contractor Doulos Environmental, Inc. License# 730042 Phone 916-990-0333 <br /> Address PO Box 2559 City/State/Zip Orangevale, CA, 95662 <br /> Consultant/Sub-Contractor Tylor McMillan's Well Service, LLC License# 9201 Phone 916-761-5224 <br /> Address 9530 Hageman Rd. Suite B#349 City/State/Zip Bakersfield, CA, 93312 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN 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(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑ OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs MW-13 4 1 ., El PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS �t "lam ® EXPLOSIVES From 100 to 20 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 /> 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 �� Title/Company Stratus Environmental, Inc. <br /> Print Name Steven Mok Date 5/23/23 <br /> DEPARTMENT USE ONLY <br /> 1, � /_�Application Accepted By: 1 /r�- ✓ Date Issued: /l_�7p_ — <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: AI Y+T6 'w4-- `-ax.7LOZ__,? <br /> Facilit /Site Information <br /> FA Name ,i , i.� S (� FA Address ` ZD t Q FA# "Z PR# <br /> FA PE WP Reviewed By Work Plan Date 3 Zoz3 <br /> ❑C-57 'k57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement ©'lead Agency Approval &MFR <br /> COMMENTS/ ONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV-D BY I DATE WELL PERMI INVOICE# <br /> Permit ZI <br /> �� ��3 $152 x ^ —J,'� blz�� YO d <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />