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SAN JOAQUIN t_C)1_►Iv-1 y SITE MITIGATION WELL & BORING PERMIT APPLICATION 1I9N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hotirs Advance Notice Required For All Inspections CALL(209) 953-7697 For INSPECTIONS Application Is hereby made.to San Joaquin County for a permit to construct and/or Install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaqldn County Well Standards. Job Address 3032 Waterloo Rd City/State/Zip 5tocklQp,CEO,. Phone (209)292-8175 Cross Street Sulro Ave APN 143-140-300-000 Property Owner' Deputy Dhallwal _ Phone (205)310.1206 Address 1233 N.Central Ave City/State/Zip Kent,WA,98032 C-57 Contractor Pene Core Drilling- License# OD6899 Phone (530)661-3600 Address 220 N.East St. Ciiy/State/Zlp Woodland,CA,95776 Consultant/Sub-Contractor Apex Envirotech,Inc License# Phone 9I 85 -0174 - --. �_._� 1� ._. Address 11291 Pyrites Way,Suite A Cfty/State/Zip Gold River,CA 95670 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offshe BodngsNVelis Require Access Agreements or Encroachment Pernik TYPE OFWELLIBORING NUMBER INSTALLATIONTYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTPACTION IVaporMlaler) ❑ HAMMEWDRIVEN DIA,OF BOREHOLE 2.5 inch9s _❑MUI UPI E CASINGS❑MUITI1 EVEL WFII CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS _ __TYPEOFCASING:❑STEEL❑PVC❑OTHER IN SOIL BORING 7 10 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes f8f No Boring Dia: Casing D'in: Casing Dcpih: [IINJECTION(Nrseoms.Ozonot ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED:❑AUGERS El HOSE 0 PIPE- D OTHER ❑ OTHER:.___,_ ____ GROUT SEAL PUMPID? ❑Yes❑No (Nola:Maztnum FrcoWl DcpUi is 3O FtI WELU SOIL BORING IDs 691,SB2,Sea,SB4,595,S96,SB7 GROUT SPECIFICATIONS neat cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION PAETHOD:(CHECK ALL THAT APPLY) 11 WELLS TO BE DESTROYED ❑OVFR•BORE DIAMETER of Inches to depth of feel WELL IDs ❑PRESSURE.GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feelbelowsurfece TREMIE TYPE TO BE USED ❑AUGERS Ll HOSE 1]PIPE ❑MUSHROOM CAP CI 3 foot below surfaco or feel below surface if>3 feet COMMENTS: �sere y certify that I am authorized to complete this application and that the work will be done In accordance with J,J San Joaquin County Ordinance Codes and Standards,and all other Mplicab}o�Ilfornla laws. Signed f Tifle/Company f `� Print Name eft)"' `c Z%t I Date SS/� DEPARTMENT USE ONLY Application Accepted By: Dale Issued:_ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facllft/Sita Information rA Name FA Addross FAfI PR# FA PE WP Reviewed By Work Plan Dale ❑C 57 ❑C-57 Aulliadza$on tmOlher"S n Permit ❑Worker's Comp ❑Worker's Camp Waiver ❑Envowhment Pearlll ❑Aomss Agreement ❑LewAgenryApproval fJ MFR COMMENTSICONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Flazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 Vvww.sjgov.org/ehd EHa 20-01 09-28-21 Silo Mingalion VM1 Parmil Application