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,�riurn,II�AI I� .tw � C O U N T Y----- '}t.rr.�?1'' Grc-atness �rr�ovs n�rt>. VfArr �0�,!\ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 9637697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or insta►I the wor{c described. This application is made in compliance with San Joaquin County Development Title, Chapter 9.1115.3, and the San Joaquin County Well Standards. Job Address \1 w � C0 6 City/State(Zip �� ( J)0 Phone �r Cross Street W %\k0sbyr1 t1J(f j,>i APN �.y�" QqQ — f c 23 '( Property Owner" 9%0"OCC VM9 TV" jt (City of Tracy) Phonewin Address 3'3 CppjQ�S`}�Q.� C�IiUJ�fl C-57 Contractor it �t W `1�i1x11 Address Consultal Address City/State/Zip Vt,Q(�,��}oh ICA � gy5�oro License# , :7A7�()14 Phone city/State/Zip Q3 al !CA 1 C1 t 0 32 License# Phone �� ttla�� 3�'2'�4r3y City/State/Zip w,j} ,l,,,E,f r(*nk IUa / L1�0`1 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Boringsr'Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q MONITORING %�j ❑``HOLLOW STEh1 BORING DEPTH c_: ' ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (VaporMlater) ❑ HAMNIER/DRPIEN DIA, OF BOREHOLE W❑ MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE E1MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL 5PVC ❑ OTHER ❑ SOIL BORING E1 PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes ❑ No Boring Dia: Casing Dia: �.a Casing Depth: El INJECTION (Nr Soame. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS ❑ HOSE I5 PIPE ❑ OTHER El OTHER: GROUT SEAL PUMPED? El Yes El No (Note: Maximum Freefall Depth is 30 FI) 1VELLI SOIL BORING IDs I -A IN 1 W I 1 1A W 3 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED IIELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED [:]AUGERS❑HOSE El PIPE COMMENTS: I here Signed i Print Name Y.U�i DESTRUCTION METHOD: (CHECi< ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feel ❑ PRESSURE GROUT To dep(h of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP El3 feet below surface or feet below surface if >3 feet by certify that I am authorized to complete this application and that the worts will be done in accordance San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Title/Company Fzl1fAMQOv' (k rtllrtt Date USE DEPARTMENT ONLY A lication Acce ted B : JEFFREY WONG 1/12/2022 PP P Y Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information th FA Name CONFIRMATION #: 136861951 SKuuti4/21 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 I F 209 464-013II � www.sjgov.orglehcl EHD 29.01 06-2r1-21 Site Mitigation RONNOCO PROPERTY of TRACY FA Address 33 CASTLEDOWN FA# FA0026949 PR# PR054740 FA PE 2950 WP Reviewed By hJ,/ Work Plan Date Submitted to EHD 1/11/22 EIC -57 121C-57 Aulhodzation for Olher to Sign Permit ❑ Worker's Comp El Worker's Comp Waiver El Encroachment Permit Access Agreement El Lead Agency Approval N MFR COMMENTS/CONDITIONS:Submit results/report to EHD per MW must be destroyed under separate permit X152 SJC Well Standards when no longer in 13.7.2 use per SJC Well Standards WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2905 313 x 3 456 " 1/4/22 WP0042905 Well Permit Application *Inspector: Obtain GPS Coordinates