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,' alLp <br /> SAN4,JOAQUIN Environmental Health Department <br /> COUNTY <br /> c9<.I `5 Greatness 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 916Frewert Road CitylStatelZip Lathrop CA,9533o Phone <br /> Cross Street APN 19126022 <br /> Property Owner' USA Waste of California Phone 510-301-9749 <br /> Address P.0.9ox793 City/State/Zip Novato,CA,94945 <br /> C•57 Contractor Penecore Dulling License# 906899 Phone 530661-3600 <br /> Address mo NEasIS1 CitylStatelZip WbomaM,CA,95776 <br /> Consultant/Sub-Contractor Geosyntec Consultants Inc License# Phone 916-637-8328 <br /> Address 3043 Gold Canal Dnve,Suite 100 CitylStatelZip Rancho Cordova,CA,95670 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsite BodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 3 ® HOLLOW STEM BORING DEPTH 25 feel ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION vapor/Water) ❑ HAMMERDRNEN DIA.OF BOREHOLE flinch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2 inch <br /> Cl SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SCH 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> Cl SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ONO Boling Dia: Casing Dia: Cashg Depth: <br /> ❑ INJECTION(AFsoaoe.0wne1 ❑ WIND AUGER GROUT SEAL DEPTH mft TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum I'melall Depth is 30 Ft) <br /> WELD SOIL BORING IDS GROUT SPECIFICATIONS Type I-V <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 sudace <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feel below surface if>3 feel <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> in Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed Title/Company Proiect GeologisLGeosymec Consultants <br /> Print Name Jamie Purcell Dale 7/20/23 <br /> EPA TMENT USE ONLY <br /> Application Accepted By: (i Date Issued: <br /> Grout Inspection By/Dates: '7 <br /> Destruction Inspection By/Dates: <br /> Facilil /Site lnforma ' n <br /> FA Name FA Address t^�Q,� FA# 100 <br /> r PR# 10 <br /> Zq' <br /> FA PE O WP Reviewed By Work Plan Dale t 2dZ <br /> 0G57 C-57AuthmintbnkrOmerto SkJn Permit ❑Workers Comp ❑Workers Gomp WaWr ❑Encroachment Permit (JAccess Agreement PAJtaJAgeMyApprmm10MFR <br /> COMMENTS/C VI <br /> ONDITIONS: 1 <br /> Foy )w. f; lt u. L)A( , , L�� .aces <br /> r S,' Fx Nli 1 t for , Ts <br /> WP TYPE PE Sc F E INFO JAMT REM) ED CHECK# RECV'D B D TE��}} WELL PERMI7T# INVOICE# <br /> Permit X 17 ( L7 oo 4-/ TZ <br /> S OD. fco <br /> 1868 E. Hazelton Avenue � tockton, California 9'fj�205 1 T 209 468-3420 LF 209 464-0138 1 slcehdFS� <br /> EHD 29-0 2104- 23 cc At j I_ � q tcl b p,5— / m 7/ ) Site Mitigation Well Pen itApplicaton <br />