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SAN MAOUIN F`nvi ronme Pita I 1-11oafth Dc�-qp�;ivvb-nont <br /> C C-)t_1 N T Y <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NQNREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2_4 Hotirs 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 9-1116.3, and the San Joaquin County Well Standards. <br /> Job Address 3032 Waterloo Rd City/State/Zip .Stockton_Q&95205 Phone _(209) 292-8175 <br /> Cross Stroot Sutra AVe APN 143-140-300-000 <br /> Property Owner* Deputy Dhaliwal _ Phono (206) 310-1206 <br /> Address 1233 N.Central Ave City/Stato/Zip Kent,WA, 98032 <br /> C-57 Contractor Pene Core Drilling License# 906899 Phone (530)661-3600 <br /> Address 220 N, East St. City/State/Zip Woodland, CA, 95770 <br /> Consultant/Sub-Contractor Apex Envirotech, Inc License# Pharte _(916 851-0174 <br /> Address 11291 Pyrites Way,Suite t3 City/State/Zip Gold River,CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED: Note: Offsite Borings/Wells Require Access Agroements or Encroachment Permits <br /> f: <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor(Waler) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.5 inches ❑MUL I IPI F CASINGS❑M11131 l EVFt.WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER t <br /> ® SOILBORING 7 ® PUSH POINT(GPI CPT) CONDUCTOR CASING [:]yes ®No Boring Dia: Casing Dia: Casing tupih: <br /> ❑ INJECTION(AR Sparse.ozonai ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ANGERS O 1IOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nola:Maximum Freofall Depth is 30 FQ <br /> WELIJ SOIL BORING IDs 8B1,SB2,SB3,SO4,SB5,Se6,SB7 GROUT SPECIFICATIONS neal cement <br /> fi <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> 1/WELLS TO BE DESTROYED ❑OVFR•BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To dep0i of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feel below surface ! <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 fool bolow surfaco or feet below surface if>3 feel <br /> COMMENTS: This permit does not include the two soil vapor wells off site as proposed in the AGE work plan <br /> here y certify that I am authorized to complete this application and that the work will be done in accordance with <br /> J San Joaquin County Ordinance Codes and Standards, and all othor, pllcab o California law . <br /> Signed tI k Tlfle/Company ' rl �` <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: JEFFREY WONG ___Date Issued: 8/25/2021 <br /> Grout Inspection By/Dates: a <br /> Destruction Inspection By/Dates: f0 2 <br /> Facllil /Silo Information <br /> i=AName Waterloo Food and Fuel FAAddress 3032 Waterloo FAfl FA0021303 PRII PR0537118 <br /> FA PE 3 527 1 WP Reviewed By IJW Work Plan Dale 1/9/2019 (by AGE <br /> ❑C•57 C•57Aulltori26on for Othor to Sign Permit ❑Workor's Comp ❑Workors Comp Waiver ❑Encroachment Permit ❑Access Agreement N Lead Agoncy Approval MFR <br /> COMMENTS/CONDITIONS; <br /> Submit copy of results to EHD per SJC Well Standards 13.7.2 <br /> WP TYPE PE SC FEE INFO AM T REMITTED CHECK# RECV'D BY DATE WELL PERMIT11 INVOICE# <br /> Permit 2905 313 $152 x 3 456 cc JW 8/24/202 WP0042477 <br /> 1868 E. hlazelton Avenue I Stockton, California 95205 ( T 209 468-3420 1 F 209 464-0138 ( www.sjgov.org/ehd <br /> "°ao-°,aa_20-21 sr008413 8 Silo Mingation Nbli Pormil/application <br /> Confirmation Number: 130604672 <br />