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r" . � SAN�JOAQUIN p <br /> °`�` Environmental Health Department <br /> <i —COUNTY— <br /> Greotness 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 209-30-015 <br /> Property Owner' LeroyOmellas Phone 209-649-8625 <br /> Address 20749 S. Lammers Rd. City/Stale/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 /> ConsultantlSub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/VVelis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporWater) ❑ HAMMERIDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: El STEEL [I PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Gazing Dial: Casing Depth: <br /> ❑ INJECTION(Aksaams.w. ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefell Depth Is30 FQ <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> Al WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of—inches to depth of feet <br /> WELL Ds IN PRESSURE GROUT To depth of 25 feet below surface <br /> GROUT SPECIFICATIONS Bentonite - Quik Grout ❑EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USE AUGERS [THOSE PIPE I�MUSHROOM CAP 3 feet below surface or 5 <br /> D [IEl ❑ feet below surface IT>3 feel <br /> COMMENTS: <br /> I liereby certify that in a hor ad to complete this application and that the work will be done in accordance with <br /> Ben J Co ty nance Codes 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 /> D PARTMENT USE ONLY / �J <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information ry <br /> FA Name e p FA Address ZI� , �Q,�-�� FAT 0O Z � b PR# 05"39-11776 <br /> FA PE ! WP Reviewed By Work Plan Date 22 <br /> 7 ❑C57Aothodrationi"Olhefto Slyn Permit ❑Workers Camp ❑Wadcals Cone Walver ❑Encroadiment PermB ❑A=Agreement ❑Lead Agency Approval ❑MFR <br /> COM ENTS/CONDITIONS:,�)� Lu �_ QV'V%-kr� n//`p.(i �,` „/K kws <br /> r>1 all {. fvv r;aw iiv e(AA - k44-kr-4 '>er- �Lq B- C3 <br /> WP TYPE PE I SC I FEE INFO JAMT REMITTED CHECK# I RECV''D 1B/Y DATE WELL PERMIT# INVOICE# <br /> Permit ?A62 I� $152 x I .5Z, C T I� 16 4/a, IW F00t53$O <br /> ppgj 38 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464- 38 1 www.sjcehd.com <br /> EHe 2"104-04-07 site Mitigation Well Parma Application <br />