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SAN JUAWN <br />SITE MITIGATION WELL (k BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />a x�)urs Advance Notice Required Fori z4 <br />CALL (209) 953-7697 For INSPECTIONS <br />Fri <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />Trris �tI at�Q s rr� g Irk �o�pgii�q with San Joaquin County Development Title Chapter 9-1115.3. and the San Joaquin County Well Standards. <br />20250 N ,1 l �1 I L HILI L�. KU THORNTON CA 95686 —� - <br />Job Address i 1 "l city/state/zip <br />Property Owner" De (A M2 r) <br />Address <br />Address <br />Consultant/Sub-Contractor <br />Address <br />W ; rt t %nom <br />Phone Ci (5; 53 � a <br />City/State/ZIP fir' r,iz r; G • C /i <br />License#� qPhone��36 <br />City/State/Zip ``, .1 t <� ,f� CI 3 (; 3 <br />'C. <br />License# <br />City/State/Zip <br />Phone <br />CONSTRUCTION WORK TO 13E PERFORMED: "Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />❑ MONITORING ❑ <br />❑ EXTRACTION (VapodWater} ❑ <br />El SOILVAPORPROBE 11[ISOIL BORING ❑ <br />❑ INJECTION (Air Sparge, Ozone) ❑ <br />❑ OTHER 1:1WELL/ SOIL BORING IDs <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMERIDRIVEN DIA, OF BOREHOLE ❑ MULTIPLE CASINGS [IMULTI-LEVELWELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING [IYes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS E)HOSE ElPIPE <br />OTHER: GROUT SEAL PUMPED? E3Yes ElNo (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED 'j <br />WELL Inc <br />1`.l 4`l - <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS El HOSE PIPE <br />Signed <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑OVER -BORE DIAMETER of inches to depth of feet <br />Q PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />MUSHROOM CAP ❑ 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 a!I other applicable California taws. <br />�--�c+t r� C <br />Date`+ <br />Application Accepted By: JEFFREY WON G <br />Grout Inspection By/Dates: A <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Title/Company ' I C 2 <br />DEPARTMENT USE ONLY <br />Date Issued: 3/9/2022 <br />FA Name 1992 N Delta Seepage Monitoring FA Address N. Staten Island FA# 0027045 P� 547549 <br />FA PE 2950 WP Reviewed By JW Work Plan Date Llly 2021 (Sheet1,2,5) <br />® C-57 ElC-57Authorization for Other to Sign Permit El Workers Comp ❑ Worker's Comp Waiver [IEncroachment Permit KI Access Agreement 0 Lead Agency Approval [ MFR <br />COMMENTSlCONDITIONS: <br />WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 2902 1313 1$152x2 304 CC JW 2/25/22 VVP0043062 <br />confirmation # 139517072 SR0084975 <br />1868 E. Hazelton Avenue � Stockton, California 95205 1 T 20946M4201 F 209464-0138 1 <br />vwwv.sjgov.org/ehd <br />EHD 29-01 06-20-21 Site Mitigation Well Permit Application <br />vwwv.sjgov.org/ehd <br />EHD 29-01 06-20-21 Site Mitigation Well Permit Application <br />