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SAN JOAQUIN Environmental Health Department COUNTY 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 Son 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 B-1115.3,and the San Joaquin County Well Standards. Job Address 23859 South Santa Fe Road City/Statelzip Rlverbank, CA,95367 Phone Chose Street Henry Road ApN 249,070-1011-00 Property owner- Jose GBnD Jr Phone (209)4804365 Address 23§59 Santa Fe Rd CIrylStatelzip Riverbank, CA 06367 C-57 Contractor Emprobe inc License# Phone 530 693-0219 Addreae P.O BOX 6093 Cltylstate/zip rave Co ConsultantlSub-Contractor Redhorea/Michael Harris License# PG#8841 Phone (510)132 4773 Address 635 Mission St 14th Floor CltylStet IZIp Send Francisco, CA 94105 CONSTRUCTION WORK TO BE PERFORMED: *Note: offsite BonngslWells RegUlre Access Agreements or Encroachment Permits TYPE OF WELLIEIMM NUMB RE INSTALLATION TYPE CONSTRUCTION SPECFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 35A ❑BOLTED TRAFFIC BOX ❑STOVEPPE 0 EXmACTIGN(V p ffl.te) E3 HAMMERMRae:N CIA.Of ROREHOI 2n O MULTPLE CASINGS❑MULTILEVELWELL CASING CA ❑ SOL VAPOR PROBE ❑ MIA ROTARY CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER NA Q SOIL BORING [3 5 ❑ PUSH PONT(GPICPT) CONDUCTOR CASING Yes ❑Ns amnia Da: C-Cho 0le: Casing Depth: ❑ INJECTION(A,s..,...ow.R ❑ HANDAUGER GROAT SEAL DEATH TREWS TYPE TO BE USED: ❑AUGERS ❑KOSE ®PIPE ❑ OTHER ❑ OTHER'. GROUT SEAL PUMPED? [I Yea ❑ Nde:MuFied4fl Wk?O F0 WEWSOILBORINGIN RWlthrouah RH-4 GROUT SPECIFICATIONS /V�-l� -IVl A E 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 depthof� -_feet below 50dace GROUTSPECIFICATIONS ❑EXPLOSIVES From to feetbolowaurfew THEME TYPE TOBEUSED []AUGERS El HOSE [I PIPE ❑MUSHROOM CAP ❑3Teetbeloasudacea feeIbelowsudawif4feet COMMENTS: sreby I authorizod to complete this app#osthm an at the work will ens in accordance,wl l oa Cry Ordinance Codes and Standards,and all other applicableCalifornia Iowa. ►/7 Signed Title/Com/oanv -- PrintNama Octa /'14l2022 - DEPARTMENT VSE ONLY Application Accepted By: 0 e Issu Grout Inspection By/Detes: '� Destruction Inspection By/Dates: Fa III SI at on FA Name n2a15 Mp,e— FAAddress q FA# 00 -?1 0 11 FA PE O WP Reviewed By Work Plan Dale H C57 ❑CST Aupcdzadoa W ehv to Sion PmM ❑Wmkaes Camp ❑Waken CwpWalver ❑EnuoadmaalPermil ❑Aapaas Afro ael Aga cyApp,-1 FIR COyM�MENTSICONDITIONS: r" y r C4� �' / o©� n a f►V f&A -41-0 wt l" D sl��i LI�,Q I lAM/ Ot CiTd S 13 . 2 n a �v i3 a WPTYPE PE SC FEE INFO AMT RENITTED CHECK# yECV'D BY DATE WEL,,L/LPER'NUTN ,p INVOICE# Permit ZgQs 152 x r� 3D �1� N �S J W ✓ -r I GIJ'riQ N rAa, Ci I t'6 I �`S`i'�-!' S r�,.,� b 162 1868 E. Hazelton Avenue I Stockton, California 96205 �r 109 6Z 420 I F 209 464-01 wwww sjCell Pm*��d�. m CHO 20•pl 0/L4-07