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SAN JOAQUIN Environmental Health Department COUNTY - Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in compliance with San Joaquin County Development This, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 4500 Stewart Road City/StatelZip Lathrop, CA 95330 Phone Cross street Paradise Road APN 213-11-003 Property Owner' Susan Dell'Osso Phone Address 73 Stewart Road City/State/Zip Lathrop, CA 95330 C-57 Contractor Geo-Ex Subsurface Exploration License# 954267 Phone Address 1510 Madera Drive CitylStatelZip Dixon, CA 95620 Consultant/Sub-Contractor ENGEO Incorporated License# Phone 925-719-0822 Address 17278 Golden Valley Parkway cityistatelzip Lathrop, CA 95330 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsNVelis Require Access Agreements or Encroachment Permits � TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l , C o`Slrl ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 55 feet ❑BOLTEDTRAFFIC BOX IYSTOVE PIPE ❑ EXTRACTION(VaporM'ater) ❑ MMERrDRIVEN DIA.OF BOREHOLE 10 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE D ROTARY CASING THICKNESS TYPE OF CASING: ®STEEL ®PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Caiing Depth: ❑ INJECTION 14 Somme.Oionel ❑ HANDAUGER GROUT SEAL DEPTH 2O-25 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IKI PIPE ® OTHER 26 ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Fq WELUSOIL BORING IDo TBD GROUT SPECIFICATIONS 10.3 Sack Mix rf" So /rai Kr /' Stfm�t5S 'v DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs [I PRESSURE GROUT To depth of feel below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED [I AUGERS [I HOSE ❑PIPE El MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feel COMMENTS: I hereby c ify that I am authorized to complete this application and that the work will be done in accordance with an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Title/Com/pany Print Name Ot fC Date l/ DEPARTMENT USE ONLY Dale Issued: Application Accepted By: Grout Inspection By/Dates, 3 Destruction Inspection By/Dates: Facilliv/Sito Information p� FA Name py1 PeJ'Mki 20 Z FAAddress I l f5CO WAY_ FA# 00 Z-_7-LiV6 O PR# FA PE Zq 5-0 W'P Reviewed By ,--)Vj Work Plan Date 1 �p 57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers GompWaiver ❑Enomachmenl Permit ❑Access Agreement ❑Lead AgencyApproval ❑MFR COMMENTS/CONDITIONS, �,�-�, I 5-e re ie-F We S A( A)or tA`(' �O t Y�c� �t�cs� rSe�P0.y� �ressur� o Ieve> �. />. , � �e 1 he fi� U ! . 1 1, 1 . WI\(CIA Oil WP TYPE PE I SC I FEE INFO JANIT FiEll 11 CHECK# I RECV'D BY 1. DATE I ,,� 77 WELL PLE�RMMIT# INVOICE# Permit 290I 313 stwx 5 . a34 t e4�55 J t2 ,/y W1 (/ ( ®T"113 .. 5Koo® _ 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-01-07 Site Mitigation Well Permit Appamlion