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SAN JOAQUIN Environmental Health Department <br /> --COUNTY <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) 963-7697 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 _ 530 North Stanislaus Street CItylStatelZip Stockton/CA/95202 phone 209-460-5000 <br /> Cross Street East Fremont Street APN 139-224-090 1" 4 .- <br /> Gerald Jones of the Housing Authority of the Count of San Joaquin ( � „ ��,- +' 209.460-5000 <br /> Property Owner* 9 Y Y q .t r I, I. ti Phone <br /> Address 2575 Grand Canal Blvd Citylstate/zip Stockton/CA/95247 <br /> C-57 Contractor TEG-Northern California License# 706568 Phone 916-853-8010 <br /> Address 11350 Monier Park PI CItylStatelZip Rancho Cordova/CA/95742 <br /> ConsultantlSub-Contractor Condor Earth License# CA PG No.9945 Phone 209.513.7834 <br /> Address 188 Frank West Circle,Suite I CItylStatelZip Stockton,CA,95206 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Vllells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL113ORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5,5' ❑BOLTED TRAFFIC BOX 11 STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) �❑ HAMMFRIDRIVEN DIA.OFBOREHOLE 2.25�Q MULTIPLE CASINGS�]MULTI-LEVEL WELL CASINGDiA <br /> 1Z SOIL VAPOR PROBE —T­❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC Cl OTHER <br /> ❑SOIL BORING ® PUSH POINT(GPI CPT} CONDUCTOR CASING ❑Yes ❑No Bodng pia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air S mo.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: n AUGERS ❑HOSE QPIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? I] Yes❑ No (Note:Maximum Freefell Depth Is 30 Ft) <br /> WELLISOILSORINGIDs ASG-1and ASG-2 GROUT SPECIFICATIONS Neat CamenlGrout <br /> DESTRUCTION WORK TO DE PERFORMED: DEST 11CT N METHOt7. CHEC I<y LL THAT APPLY ��'!+ <br /> #WELLS TO BE DESTROYED ®OVER-BORE DIAMETER of 2•25 inches to depth of 5.5 feet 0-V r 4 <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface F 1 <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface 11177711t <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE MUSHROOM GAP ❑3 feet below surface or feet below surface if 53 feet <br /> COMMENTS: ASG-1 and ASG-2 will be destroyed pursuant to SJCEHD Well Standards <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> Spin Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed (!/_ 4.4 'Title/Company Associate Geologist/Condor Earth <br /> Print Name Luke Castle D81e 4/23/2024 <br /> DEPARYMENT USE ONLY f <br /> Application Accepted By: ��_ _ Date Issued: L/ [� <br /> Grout inspection By/Dates: <br /> Destruction Inspection By/Dates' <br /> Fa Ili /site Information <br /> FA Name k FA Address 04 c , FA# �] ( PR# <br /> FA PE �( WP Reviewed By Work Plan Date <br /> ❑C•57 C-57 Amir; nation for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Parmh ❑Access Agreemerll ❑tead Agency Approval MFR <br /> cOMMENTS! ONDITIONS. <br /> WP TYPE PE so FEE INFO AMT REMITTED CHECK# RECVrD BY DATE // WELL PERMIT# INVOICe# <br /> Permit7 '1 � $162x � r 11 LT 1 �1 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 209 46$-3120 I F 209 464,01 8 1 www.sjgbv.orglehd <br /> EHp 29-ol 06-28-21 Silo MItig lion Woll Pormlt AppliMtlDP <br />