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• t ""t]�gfv . SQNa�JOAQUIN Environmental Health Department COUNTY— g,I,, 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 2478 North Wilcox Road City/State/Zip Stockton, CA 95215 Phone Cross Street Waterloo Road APN 101-021-74 Property Owner* Wiley and Shawn Chandler Phone Address PO Box 507 City/Stale/Zip Stockton, CA 95207 C-57 Contractor PeneCore Drilling License# 906899 - Phone 530-661-3600 Address 220 North East Street City/StatelZip Woodland, CA 95776 Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsile BoringsNVells Require Access Agreements or Encro41 achment Permits SC�y4N A A , TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS AbYI ` �3e� ,�37 G9 MONITORING 3 IM HOLLOW STEM BORING DEPTH 80It ❑BOLTED TRAFFIC BOX ❑ TO PE ❑ EXTRACTION(VaporMater) ❑ HAMMERNRIVEN DIA.OF BOREHOLE Bin ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS 2in TYPE OF CASING: [I STEEL ®PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING [I Yes ®No Boring Die: Casing Dia: Casing Depth: ❑ INJECTION(axswae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIETYPETOBE USED: ❑AUGERS 010SE ❑PIPE ❑ OTHER ❑ OTHER; GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING Ins MW-1 MW-2, MW-3 GROUT SPECIFICATIONS a14a �" Py �r IJ,AI- r -JF v z ZOTN 5. , DESTRUCTION WORK TO BE PE RF L_. i ��ESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 13'e • ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑ PRESSUREGROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feelbelowsurfam TREMIE TYPE TO BE USED ❑AUGERS [I HOSE )❑PIPE ,,I ❑ MUSHROOM CAP ❑l 3 feet below surface or feet below surface if>3 feel .COMMENTS: BjOp, Q W GLV -��3. �/["�1 cd s ARCr_ Cf certify one In rill CVl I hereby certity that I am authorized to complete this applicatlon and that the work will be done in accordance With � � San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed "/7�nri/p_//� Title/Company Staff Geologist, Stratus Environmental Inc. Print Name Steven Mok Date 01/12/23 _QEPARTM ENT USE ONLY I /^ a Application Accepted By: rrl Date Issued: _�r� n i- Groul Inspection By/Dates: vic Y2V'�`R 9-1';L 2o2J Destruction Inspection By/Dales: Facllit /Site Information FAName FAAddress (� 07 FA# I ©() :-SU PR# 1064K 20 FA PE WP Reviewed By LAi Work Plan Date q Z 3/Z Z W /�E6 ❑G57 7Aulhodxa6an for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encro me tP_mi Access Agree A ncy ppr0�+�1 R b YEN ln10 COMMENTSICONDITIONS: n/Of p1�•� (>Z ' ry pl IZ.j�g �• y �, �oylp�I, bu 1 Pror sfRr l w� wr. r0 v2rs rtlY 1 Ps sR djl�i/lu !l( s [o W WP TYPE PnE SC FL INFO AM ED •C^HE^CK# RECV'D BY DATE , )WELL PERMIT# INVOICE# Permit ID ` -x I IZ3 V'r O�� cc! SS Z 8'q_g1-� S !P-00 s6 30? fT 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 46 -3420 1 F 209 464-0138 1 www.slcehd.cc / /� EHD 29-010q-04-W t`.�. I' �pf L�. /}- \ c 156150 5IL � ` Site Mltigatiop Well Pfririt infion f. ,{['[(�Z, /Jb�J_I s1L1 2