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SAN JOAHIN 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) 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 wilh San Joaquin County Development Title, Chapter 9-1116.3, and the San Joaquin County Well Standards, <br /> Job Address 4600 Stewart Road(adjacent to) cltylstatelzlp Lathrop, CA 95330 Phone <br /> Cross Street Paradise Road APN 213.12.006 <br /> Property Owner' Susan Dell'Osso Phone <br /> Address 73 Stewart Road cilylstatelzip Lathrop, CA 95330 <br /> C-67Contraclor West Coast Exploration LicenseN 870761 Phone 9n9- QRS_7S6I <br /> Address PO Box 133 Clly/Statelzip Escalon, CA 95320 <br /> Consultant/Sub-Contractor ENGEO Incorporated License# Phone 925-719.0822 <br /> Address 17278 Golden Valley Parkway cllylstate/zip Lathrop, CA 95330 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: ONsile Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER NUM13ER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORINGDEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vap paler) ❑ HAMMEIVURNEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑M.ULTI•LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSHPOINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bang Oa: Casing Dia: Casbp Depth: <br /> ❑ INJECTION yesomee.orone ❑ HANDAUGER GROUT SEAL DEPTH TREME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Msimum Freefal Depb is30 RJ <br /> WELUSOR BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO3EDEVrRO1 $]OVER-BORE DIAMETERof 6=lmheslodepthof 25 feel <br /> WELL IDs - ❑PRESSURE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS neCILL cement- ❑EXPLOSIVES Fmm_to feel below surface <br /> TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet <br /> COMMENTS: Well is n0 longer needed on site . <br /> I h re y certify that I am authorized to complete this application and that the work will be done in accordance with <br /> 9a o uloCounty Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed / — -?Title/company Project Geologist-ENGEO Incorporated <br /> anon Sedore - ----_-- <br /> Print Nama Date 12/28/2022 <br /> i <br /> DEPARTMENT E ONLY <br /> Application Accepted By: 1 �, y�_(%i Dale Issued: <br /> Grout Inspection By/Datesi l - 1 _r,-�-- <br /> Destruction Inspection By/Dates: <br /> Facllll /Site Information / <br /> FA Name L t- ILLivi Vvl i FA Address 1. 1- 0 U � � vL'C V�C FAN CR_r C -� �, j PR# <br /> FA PE ZO ' (� WP Reviewed By ;'j— ✓l, Work Plan Dale <br /> ❑C-57 GS7 Auftrhalan kf OtIa to Sign Pendt ❑Wakmis Corry ❑W'akefs Cara Walva ❑Emoachment Pemi1 ❑Atcess Agreenm l ❑LeadAgemyApprovaf MFR <br /> COMWENTS16 NDRIONS: ' <br /> d ket / M W S Stets� fj osti r�` 1� � JA�1Aun2 <br /> WP TYPE PE I SC I FEE INFO I JAMT REMIT/T'ED CHHE/CpK# RECV'D BY DATE WELL PE�RyMIT# INVOICE# <br /> Permit 410 �, 5�3�1 10 � I�f7� .� - I' '�rr/Z3 Wf60 -1 <br /> Llr- <br /> 1868 E. Hazellon Avenue I Stockton, California 95205 1 T 209 468-3420 1 IF 209 464�8 ¢ft. jcehd.com <br /> BED 29-0104-0407 Site Mlipelon Well Pemil Appewr <br />