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opoulN c iff�0`z SANJOAQUIN Environmental Health Department !k�i —COUNTY— Greatness grows here, j 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) 963-7697 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 3333 $gnTh 1q tcltCj FrenTggc ROA.1 _cltylstalelzip em,&5en i 4n t"Fornia Phone �176)�1203 Cross Street (Poo Lag a j"TeNacT. soNTMAPN 630_- 000 fl fw w awvw-z aln _ WafTFroAr. c K" A Phone Property wift Address Ga70 forIwr lStatefzip ncwaOhl AALIWA 34t1os C57 Contractor Confluence Technical Services Inc License# 1035255 ( I *hone 707-639-7709 Address 6821 8th Street City/!State/Zip Rio Linda a 95673 ConsultantISub-Contractor ERZ CeASNRrng _License# F.J. rJ •11-10 Phone C�Rg�945"730� Address AI 6 011T461r.04 (Ryaf/f Sys► Cltylatatelzip 6arllmrn MA 01463 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offaite BoflngSANells Require Access Agreements or Encroachment Permits TYPE OF WEL.UBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BOWNG DEPTH ', ,&T ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vap Mato) CBIHAMMERMRIVEN OIA.OF BOREHOLE ❑MULTIPLE CASINGS(3 MULTI-LEVEL WELL CASING DIA GYSOILVAPOR PROBE 11,4f, ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No.BWrg Die: Casing Die CMIng DOPth: ❑ INJECTION IAF&moaor ) ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Nob:Mad un Fmbl Depth)S 3o Fp Y' WELLISOILBORINGIN `'6.1 Th1Y wr�M R.'9 GROUT SPECIFICATIONS In CI^ 1 a / &Welt{ i 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 ❑PRESSUREGROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From—to-feet below surface TREMIE TYPE TO BE USED ❑AUGERS Q HOSE ❑PIPE 0 MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that am authorized to complete this application and that the work will bodone— In S,�o.n��Jo��aquui]i��n��Co�u�n�LtyOrdinance Codes'snd Standards,end all other applicable California laws, Signed �l.t�i &n6Ay^^r�,T TitlelCompany Senior Pr,;' T Man 414tr Print Name AWT 154r.Aslc Date APr it air 7wgrt 1� DEPARTMENT USE ONLY Application Accepted By: f/I/ Date Issued: I I'L Grout Inspection By/Dates: L ! L S! C/�7jy o Destmction Inspection By/Dates: Facilltv/Site Information FAName .yyl (y C ,& FAAddrass 333' H; W FA# 00 Z$7 130 PRO FA PE 2 9 50 1 WP Reviewed By I -j-i;') I Work Plan Date 0057 Cf51AdWfza50nfurOuwto Sqn PaanR ❑W~soonp ❑Wake'&Comp W&&r ❑Emmaclunm1Fwmk ❑Access Agreement 0LesoA90 Approval MFR COMMENTS/CONDITIONS: rE.P 6Y'-� OIT- nl'i.nr� .F�I9 ptr J j C Wall ,St,xA WP TYPE PE SC I FEE INFO JAMT REMITrED,CHECK# RECV'D BY I DATE j WELL PERMIT# INVOICE# Pem)it 2go5 313 $162X j 4C� Svc r j 2 W ° It5�17 ec Igoe 0 OIL1� S(CoaS �gBR 1868 E. Hazellon Avenue I Stockton, California 96205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehcr.com EN020-01 7-01-2023 Site MIUgaUw Wee Pw1IAppkAtw