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rpU1N�. <br /> SAN,IOAQUIN Environmental Health ment <br /> —COUNTY— IVSD <br /> lt'po- <br /> Greatness grows here. ^ 1 r{? <br /> SITE MITIGATION WELL & BORING PERMIT APPLICAT� a <br /> For Wells And Borings Used for NON--REFUND BLE PERMIT EXPIRES 1 YEAR FROnt M DIATE ISSUED ons emedlap SE'AWC S1T({ <br /> 48 Hours Advance Notice Required For All 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 1502 E. March Lane city/stat ip Stockton, CA 95201 Phone <br /> Cross Street West Lane APN 096-140-24 <br /> Property owner King of Central Valley II Phone <br /> Address P.O. 1547 City/state/zip San Ramon, CA 94583 <br /> C-57 Contractor Gregg Drilling&Testing License# 485165 Phone 925-313-58100 <br /> Address 950 Howe Road City/state/zip Martinez, CA 94553 �o 6n <br /> Consultant/Sub-Contractor ATC Group Services LLC License# Phone 209-579-2221 <br /> Address 1117 Lone Palm Avenue,Suite 201B City/statelzip Modesto, CA 95351 ?R-52`1 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 1 ❑ HOLLOW STEM BORING DEPTH 65 ft. M BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLEIn ❑MULTIPLE CASINGS 13 WELL CASING DIA <br /> [I SOIL VAPOR PROBE El MUD ROTARY CASING THICKNESS ❑TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(SPY CPT) CONDUCTORCASING [I Yes ®No Boring Dia: Casing Dia: Cazing Depth: <br /> ❑ INJECTION IAIrsoaue.ezonel ❑ HANDAUGER GROUTSEALDEPTH 45 ft. TREMIE TYPE TO BE USED: ®AUGERS El HOSE ❑PIPE <br /> ❑ OTHEROTHER: GROUT SEAL PUMPED? []Yes ®No (Note:Maximum Freefall0epth Is 30 Fp <br /> WELD SOIL BORING IDs /1'j GROUT SPECIFICATIONS neat cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:/CHECKALLTHATAPPLYI <br /> #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 El EXPLOSIVES From—to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE El MUSHROOM CAP [:13 feet below surface or feet belay surface if>3 feet <br /> COMMENTS: <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 Title/Company ('�,..-r <br /> - � Print Name r/ le aJAL4A y Date <br /> T <br /> — � DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facillt /Site Information <br /> FA Name FA Address2 6 _ _ p / FA# nl'71 PR# xh <br /> FA PE s7 f�i WP Re ' ed By 4 u/��G�-i V Work Pian Date l" �V <br /> 57 0C-57Authorizallon for Otherto Sign Permit orkers Comp ❑Workers Comp Waiver ❑Encroachment Permit Access Agreementad Age Approv R <br /> COMM ENTSICON DITI ONS: <br /> WP TYPE PE SC FEE INFO MT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit <br /> Z0d J 152x I S -- 0 7 J <br /> .rfM 7 7 <br /> 1868 E. Hazelton Avenue I Stockton, al'Iforn' 95205 1 T 209 468-3420 1 F 209 4�6�4-0138 1 www.sjcehd.com <br /> �.n EHD 29-0108-01-17 - ye Miti�o rigeitxar,ypgtion <br />