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SAN JOANIN 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 Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 4500 Stewart Road rj'=—City/Statelzip Lathrop, CA 95330 Phone Cross Street Paradise Road APN 213-11-004 Property Owner* Susan Dell'Osso Phone Address 73 Stewart Road City/StatelZip Lathrop, CA 95330 C-57 Contractor Geo-Ex Subsurface Exploration License# 954267 Phone Address 1510 Madera Drive City/State/Zip Dixon, CA 95620 ConsultanUSub-Contractor ENGEO Incorporated License# Phone 925-719-0822 Address 17278 Golden Valley Parkway City/State/zip Lathrop, CA 95330 CONSTRUCTION WORK TO BE PERFORMED: *Note: OUsile Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLISORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 55 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapuMater) ❑ HAMMER)DRIVEN DIA.OF BOREHOLE 10 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE �MUD ROTARY CASING THICKNESS TYPE OF CASING: ®STEEL ®PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORGASING ❑Yes ❑No Boring Dia: Casfrg Dia: Casing Depth: ❑ INJECTION/Fiseeree.0, ❑ HAND AUGER GROUTSEALDEPTH 2O-25 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 91PIPE ® OTHER 2 ❑ OTHER: GROIrr SEAL PUMPED? 91 Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELUSOIL BORING IDs TBD GROUT SPECIFICATIONS 10.3 Sack M' _ b( n I C rA.� b A I,yti DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of—feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface it>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done In accordance with San in County Ordinance Codes and Standards, and all other applicable California laws. r Signed TftlelComPany S Print Name « Date //r? Z DEPARTMENT LISE ONLY l 2 Application Accepted By: Date Issued: Grout Inspection By/Dales: Destruction Inspection By/Dales: ! �' Facilil (Site Into I n //'' FAName YD 6M �Il,l- FAAddress I tI5CO > ..(?y\/�-{'� FA# 0 PR# FA PE 2 WP Reviewed By ,�k' Work Plan Date G57 0G57Aulhodzaflen for0ther to Sign Permit ❑Workers Comp ❑Workers Comp Walver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COM ENTS/CONDITIONS: /Ul/c .� �7�( 1nJe 5 m✓e tr rfoSe- o-V r J C; Aq •cWQ. ff5 UhB-- 4-0 -�� Ieve-e— syf aA I / a Wsc ✓Jells Mvs b - desjro e d uA je'r I r IA/ 1 P PA AO lmg r , 1\ WP TYPE PE SC I FEE INFO JAMT REmirrEDI CHECK# I RECV'D BY DATE I WELL PERMIT# I INVOICE# Permit Noll 313 s%I,6 �6 31 `)-> 11 1 1 /2 z V Pao 413 SI'0o 3 l a 1868 E. Hazelton Avenue Stockton, California 95205 �& 3_4'y/�T� 209 464-0138 �cel�r EMD 29-0704-04-07 t 1I� /Sne'hian�,Tel er lA(/gA� n 3