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�'"� �`"`• SAK OAQUIN Environmental Health Department <br /> COUNTY— <br /> r 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 21070 S. Reeve Rd. city/State/Zip Tracy, CA 95304 Phone 209-649-8625 <br /> Cross street S. of Bethany Rd., East side APN 209-30-016 <br /> Propertyowner* LeroyOrnellas Phone 209-649-8625 <br /> Address 20749 S. Lammers Rd. City/State/Zip Tracy, CA 95304 <br /> C-57 Contractor Hennings Bros. Drilling Co. License# 290813 Phone 209-545-1185 <br /> Address Hennings Bros. Drilling Co., Inc. city/State/Zip Modesto, CA 95356 <br /> ConsultantfSub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaponWater) ❑ HAMMERMPJVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS[I MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Cssing Depth: <br /> ❑ INJECTION(Aksomm oiooel ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Frcefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 7 ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ®PRESSUREGROUT Todepthof 25 feet below surface <br /> GROUTSPECIFICATIONS Bentonite - Quik Grout ❑EXPLOSIVES From to—feet below surface <br /> TREMIE TYPE T EUSED ❑AUGERS HOSE ❑PIPE QrJ MUSHROOM CAP ❑3 feet below surface or 5 feet below surface if>3 feet <br /> COMMENTS: <br /> jr ereby certify that I a th iz to om late this application and that the work will be done In accordance with <br /> San Joaq unt r n odes and Standards,and all other applicable California laws. <br /> Signed Title/Company V.P. / Hennings Bros. Drilling Co., Inc. <br /> Print Name Sean Roddy Date June 1, 2022 <br /> DEP TMENT USE ONLY <br /> Application Accepted By: I A Date Issued: <br /> Grout Inspection By/Dates: r ZZ <br /> Destruction Inspection By/Dates: 1134 <br /> Facilil /Site Information <br /> FA Name FA Address Z(0 '110 $ , FA# o Q 91 I Pfv I Q 53!9 <br /> FA PE WP Reviewed By Work Plan Dale <br /> 7 ❑G57Autiwizationfor Otherlo Sign Permit ❑Workers Comp ❑Workers Comp Walver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: 2 > � Piz <br /> 7 Iv McUC. 4 eµy� e� 5 v <br /> �rsss rotes t S cote Mtj w(¢12 ;Iq ?, , f% ran fAt� re(eaSel pzr RBI C8 <br /> WPTYPEJ PE SC I FEE INFO JAMT <br /> �RE/MITTED CHE�7CK# RECV'D BY DATE �.IWELL PERMIT# INVOICE# <br /> -d pp <br /> Permit lOZ 3 `� $152x Q otf }310 7 Zz WQM 433- <br /> 3R«0 633941� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcohd.com <br /> EHD 29-0104-N4 07 Site Mitigation Well Pennit Application <br />