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SAN JOAQUIN <br />COUNTY <br />41d j� <br />,, „ter Greatness grows here. <br />Environmental Health Department <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 916 Frewert Road <br />Cross Street <br />Property Owner* USA Waste of California <br />Address 10840 Altamont Pass Road <br />C-57 Contractor PeneCore Drilling <br />Address 220 N East St <br />Consultant/Sub-Contractor Geosvntec Consultants Inc <br />Address 3043 Gold Canal Drive. Suite #100 <br />City/State/Zip Lathrop, CA 95330 Phone <br />APN 19126022 <br />Phone 510-301-9749 <br />City/State/Zip Livermore, CA 94551 <br />License#q Phone 530 661-3600 <br />City/State/Zip Woodland, CA 95776 <br />6 <br />License# <br />City/State/Zip Rancho Cordova, CA 95670 <br />Phone 916-637-8328 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF MCI <br />LIBORING NUMBER <br />❑ MONITORING ❑ <br />❑ EXTRACTION (Vapor/Water) ❑ <br />❑ SOILVAPORPROBE El[ISOIL BORING ElElINJECTION(AirSoarge,Ozone) ❑ <br />El OTHER ❑ <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH <br />HAMMER/DRIVEN DIA, OF BOREHOLE <br />MUD ROTARY CASING THICKNESS <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes El No <br />HAND AUGER GROUT SEAL DEPTH <br />OTHER: GROUT SEAL PUMPED? El Yes El No <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 1 <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ®AUGERS ❑HOSE 171 PIPE <br />COMMENTS: <br />Signed <br />❑ BOLTED TRAFFIC BOX ❑STOVE PIPE <br />ElMULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: El STEEL E] PVC E] OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TRE TYPE TO BE USED: El AUGERS El HOSE El PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />® OVER -BORE DIAMETER of 8 inches to depth of 15 feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP E]3 feet below surface or feet below surface if >3 feet <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 />Title/Company Senior Geologist, Geosyntec Consultants <br />Print Name Nicole Gotberg Date November 22, 2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />FA Name <br />Rid 24 6 <br />FA PE <br />O <br />WP Reviewed By <br />�� <br />Work Plan Date <br />` <br />l 2 Z <br />ElC-5757 Authorization for Other to Sign Permit ❑ Worker's Comp E] Worker's Comp Waiver El Encroachment <br />Permit <br />El Access Agreement ead Agency <br />Approval R <br />COMMENTS/CONDITIONS. <br />�t e L cl <br />/v <br />,e or s <br />� <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permitq0Z <br />31 <br />$152 x <br />1 5�266� <br />Zb <br />l <br />IYv l oo 4 � 1q <br />�-3 <br />1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjgov.org/ehd <br />� <br />EHD 29-01 06-28-21 Site Mitigation Well Permit Application <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />s � � <br />