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SAN JOAQUIN Environmental Health Department <br /> —COUNTY <br /> Greatness grows her, . <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 Inslell 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 -- 00 S California AvAde Cllylstatelzip Stockton, CA 95203 Phone 209-466-4953 <br /> Cross street Lafayette Street APN 149-09-501 <br /> Property Owner* Sharon OIIVarez Phone z09-46Pr4953 <br /> Address 540 W. Scotts Avenue city/StatelZip Stockton. CA 95203 <br /> C-57 contractor Gregg Drilling LLC License# C57-1044466 Phone 926-313-5800 <br /> Address 950 Howe Road CltylStato/Zip Martinez, CA 94553 <br /> Consultant/Sub-Contractor Ground Zero Analysis. Inc. License# PG: 5023 Phone 209-522A119 <br /> Address 1172 Kansas Avenue Cltylstateizlp Modesto. CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: ONsile BadngsAVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICAIIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTEDTRAFFICBOX ❑STOVEPIPE <br /> ❑ EXfRACmDN1(Vapxlwalei) 0 HAMMEW9PIVEN DN.OF BOREHOLE ❑MULTIPLE CASINOS O MULTI-LEVELWELLCASING DW <br /> ❑ SOILVAPORPROBE ❑ MUD NOTARY CASING THICKNESS TYPEOF CASING: OSTEEL OPVC 0 OTHER <br /> ❑ SOILBOIONG _❑ PUSHPOINT(GPICPT) CONDUCTORCASING ❑Yes ONo Bednift Ce*vM CmMg DepN: i <br /> O IUJECTIONWaoxeaormel ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPE 10 BE USED GAUGERS OHOSE ORPE <br /> ❑ OTHER ❑ ORIEIC GROUT SEAL PUMPED? 13Yes ONo (Note'.Madmen Reefal Depth is 30 Fit <br /> WEW SOILSORING IDs GROUT SPECIFICATIONS <br /> _ DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: aigLL THATAPPL �iY 2 <br /> #WELLSTO BE DESTROYED I6(10 MWs; 1 EW 5 Vapor Wells) I@OVER-BORE DIAMETER of Inches Wdepthof 3 Iee�af�Ci'L e <br /> WELL IDS Sea well names below In Comments []PRESSURE GROUT Todeplhol feetbebweudaw R <br /> GROUT SPECIFICATIONS Neal cemenfgroul IR EXPLOSIVES Fragbotiom�wl0 faetbel"Mriam <br /> THEME TYPE TO BE USED []AUGERS SE ®PIPE ®MUSHROOM CAP 193feelhdowsurlacea feetboloasudaceif4faet <br /> - COMMENTS: - <br /> e following Ila II be destroyed:�Mywl <br /> -1R 2 -3R W-1 W- , W-5, W- W-7s W-9 a EW- ISoll Vapor wells:SV-1 thru SV 5 <br /> b r t • <br /> 1 hereby tort he a oriz o ete t app ca o fha o Will ne acc dance wl <br /> San Joaquin County Ordin ce Codes ands dard ,and all other applicable Ca Ifornia la A. <br /> Signed 41— Title/Company Project Manager,Gregg Drilling,LLC <br /> Print Name Ryan Lea Dale 412MO24 <br /> EPARTM T USE ONLY / � _ <br /> Application Accepted By: Dale Issued: ( l�� <br /> Grout Inspection By/Dot" <br /> Destruction Inspection Symalesf <br /> Facili (Site I for atlo <br /> FA Neme AAddrass Qb ( rAi <br /> FA PE Z 1VP Reviewed By I I WM Plan Date <br /> 57 ❑C67Aitt ruafonfarpowto611Pemul ❑Wakens Cary ❑wMarsCne)WAva OrycmadmeniFemRl ❑AaessAlleement AgerMARs"al <br /> COM MEN SICONDITIONS: - i Tc� Co Nre-rj �Fj U,Y� <br /> s <br /> �T crLM 6y- re Lake�L -tvW� a.b 0 J.2 <br /> WP TYPE PPIEyy SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE 1WELL PERMIT# INVOICE# <br /> Permit -e jo 3 1 $162 x 5 iS� c c Z� W�06 q <br /> 0 00 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 4 - 4201 IF 04�9 46138 I www.sj ehd.com <br /> EHD 29.017-et-2023 aRa MNaetlon N4l Pemtrippprstlan <br />