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0AN JOANN <br /> F nnl6 um,1G Iroe6I' Cu)cgp)F R-1j o-ol on <br /> - C O U I`J T Y--- - <br /> WE M9-Y IG TM WELL, & BORING- PE 'bl�li6_F AT'PUG MON, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 E-Iol_ rs Advance Notice, Required For All InspWcticii-i's <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 Beneath 1-5 from W Fremont St to W Weber Ave and Its vicinity CitylStatelZip Stockton, CA Phone <br /> Cross Street N Pershing Ave and W Washington St APN No APN, Caltrans ROW <br /> Property Owner* Caltrans Phone 209-471-7197 <br /> Address 1976 MLK Jr. Blvd City/State/Zip Stockton, CA, 95205 <br /> C-57 Contractor Geocon Consultants, Inc. Licensef/ C57, 716050-A Expires 12/31/2025 Phone 916-852-9118 <br /> Address 3160 Gold Valley Dr.Ste B00 CitylStatelZip Rancho Cordova, CA 95742 <br /> Consultant/Sub-Contractor Address LicensefE Phone <br /> City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2,25" ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVc ❑ OTHER <br /> ® SOIL BORING �❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIETYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER [2 OTHER: Direct Push GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPEC]FICATIONS Neat Cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> It WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [:]HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San acluln Coui}y Ordinance Codes and Standards, and all other applicable California laws. <br /> Signedw°:yI Title/Company Construction Services ManagerlGeocon Consultants, Inc. <br /> Print Name ROBERT M. KIMBALL Date z2-1 <br /> DEPARTMENT USE ONLY M <br /> Application Accepted By: Date Issued: <br /> i <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: 6119"— !Q --z_ -a;q <br /> Facilit /Site Information 66 <br /> FA Name �4 +vqh) 1-5 VI0. YCi ')FAAddress _ Xt P,63 ;k K h FA# 007 <br /> 7" R'C? `"1 PR# o <br /> FA PE `��'] � WP Reviewed By r_ Work Plan Dale <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMITf# INVOICE# <br /> Permit $172 x W <br /> ,sll � J/fit r 2-4bn 2, � <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 04-20-23 !� J? p 1- v( Site Mitigation Weli Pen-nit Application <br />