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SAN JOAQUIN Environmental Health Department <br /> COUN-Y <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 With San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 236593 South Santa Fe Road Cltylstatel2Ap Riverbank,CA,95367 Phone <br /> Cross Street Henry Road APN 249-060-0904D00 <br /> Property Owner' City of Riverbank Phone (209)490 4365 <br /> Address 6707 3rd Street City/Statel ip Riverbank,CA 95367 <br /> C-67 Contractor Enprobe Inc License# C57# 1012248 Phone 530 693-0219 <br /> AddressP.O Box 6093 Cltylstate2lp Ciroville CA 96966 <br /> ConsultanUSub-Contractor Redhorse/Michael Harris License# PG#8641 phone (510)432 4773 <br /> Address 636 Mission St 14th Floor Citylstetelzip Sand Francisco,CA 94105 <br /> CONSTRUCTION WORK TO BE PERFORMED!*Note: Offsite BoringsAVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 35X ❑BOLTED TRAFFIC BOX ❑STOVE PPE <br /> ❑ EXTRACTION'ValoorWater) ❑ HAMMERDRNEN DIA.OF BOREHOLE 2 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER NA <br /> [� SOIL BORING 1 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Da: Casing Dia: Casing Depth. <br /> ❑ INJECTION Nr sseme Dowel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE El PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No Ni Maximum Frecldl Depth is 30 Ft) <br /> WELLI SOIL BORING to. RH-5 GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <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 ❑EXPLOSIVES From to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS []HOSE ❑PIPE ❑MUSHROOM OAP ❑3 feet below surface or feet below surface if 13 fret <br /> COMMENTS: Off-site boring <br /> I reby that 1 am audtoft ed to complete this apppcadon and that the work will be done In accordance with <br /> !4 uin County Ordinance Codes and Standards,and all other appllea/Me California laws. <br /> Signed TitlelCempany �!A-'Al%J _.. <br /> Print Name Dennis tt Date 04 M4/2022 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: _. Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Fecili /Site Information — <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By I Work Plan Date <br /> ❑G-57 ❑C-57 Authwd.tiara fo,Other to Big,Permit ❑workees comp ❑worear s Cenp Waiver ❑Fncmadment 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 PERMIT# INVOICE# <br /> Permit 152 X <br /> 1868 E. Hazelton Avenue I Stockton, California 96206 1 T 209 468-3420 1 F 209 464-011 38 1 welww�sjcAeP d.caom <br /> EHD 2M1 04-04-07 site mitgai <br />