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ti <br /> >uo,p <br /> SAN1J0A0UIN Environmental Health Department <br /> —COUNTY <br /> s� s <br /> 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 vAth San Joaquin County Development This,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address RT 4 Postmjle SJR17.068 CitylState/Zip Stockton, CA 95203 Phone 209-5224119 <br /> Gross street None -Is under HWY 4 Off Ramp Exit 66 APN <br /> Property Owner' Caltrans -Joseph Valdez Phone 209-601-5074 <br /> Address D10 Encroachment Permits: PO Box 2048 city/statelzip Stockton. CA 95201 <br /> C-57 Contractor Gregg Drilling LLC License# C67-1044456 Phone 926-313-5800 <br /> Address 950 Howe Road citylstato/Zip Martinez, CA 94653 <br /> Consultant/Sub-Contractor Ground Zero Analysis, Inc. License# PIS: 5023 Phone 209-5224119 <br /> Address 1172 Kansas Avenue citylstateizip'Modesto, CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: OffsHe aodngsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICA71ONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑UMTEDTRAFFICBOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapo[ M*r) _0 HAMMERATMVEN DIA.OF BOREHOLE ❑MULTIPLECASINGS O MULTI.LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MODROTARY CASINGTHICKNESS TYPEOF CASING: OSTEEL ❑PVC 0 OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPICPT) CONDUCTOR USING ❑Yes ONo Boring Dix Ca4q Dla: Cas4g Warr <br /> ❑ MJECTIONWaerae.0me _❑ HANDAUGER GROAT SEAL DEPTH iREMIEIYPETO SE IIS®.' ❑AUGERS ❑HOSE ❑FIFE <br /> ❑ OTHER ❑ OTHER GROUrSEALPUMPED7 DYes DNo (Note:Mmkmm Freeran Depth k 3D Fit <br /> WEWSOILSORINGIDS GROUT SPECIFICATIONS e.,r: SfM � U✓ <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD, c Et ALL L 'j uJ <br /> #WELLS TO BE DESTROYED 1 IN OVER BORE DIAMETER of In todepihof 3 lest <br /> WELL IDS MW-11 ❑PRESSURE GROUT To depth of `�. feel balm surface ' <br /> GROUT SPECIFICATIONS Neal cement grout ®EXPLOSIVES FromboilomyTo 10 feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS [I HOSE 14PIPE ® 1213tealbelowsurraceor feat below surface lf> feet <br /> COMMENTS: ` ( e . 1 r 1\ 1_ �, i �� ^ Q � -/�n <br /> M �V V Imo"^ WVdC <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed AZ_ Title/Company Project Manager,Gregg Drilling,LLC <br /> Print Name Ryan Lea Date 4/292024 <br /> EPA M T USE ONLY > <br /> Application Accepted By: Date Issued: �`•D W z <br /> Grout Inspection By/Dal <br /> Destruction Inspection By/ r <br /> Facllit /Site Information <br /> FA Name /' FAAddress OO FAN — PR# I O <br /> FA PE 7 p WP Reviewed By Work PIm Dale <br /> C57 ❑C57A odrallonforO0erkslo Pemth ❑Workets Cane ❑VANWsCompWa4rer Ercmeahnent Pemtlt ❑AaasAgreemBM LeadA"Appral FR <br /> COMMENTSICONDITIONS: <br /> ,.re> l[ c row " .--reno la ce- . <br /> WP TYPE I PE I SC FEE INFO AMT REMnTEDj CHECK# RECV'��D��BY ATE WELnLnPERMIT# INVOICE# <br /> Permit QZ 3 ) s162x CC W 4' 3p �—W Vv <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468 <br /> 4 F-2 9 464-0 38 I wwww.jcehd.com <br /> EHa 29417-01-2023 Ske M111g;k1w Wore Permit AppMgAon <br />