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JEFFREY WONG Application Accepted By: <br />Grout inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Date Issued: 10/22/202 1 <br />SAN JOAQUIN <br />---COUNTY-- <br />Environmental Health Department <br />Grootness grows here. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <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 '60nri Pjarki-s , 3 6145 6as+ Mil-hin Rd <br />Cross Street N. folt 12_6 0t <br />Property Owner" AID.bani fct vrti et'S Coopera.shk. toc • <br />city/State/ZIp bec.a.ii-sr, AL 55'401 Address 12 I Sowierv'itR V-d G , A L <br />C-57 Contractor le.thr,9 ow% Dy I I ly19 <br />Address 13 12 "Flvti..fon -4 filvel J&H Drilling <br />Consultant/Sub-Contractor k44-401b1S.1-Dn <br />Address 2 CO Cybi."/ Carly° d St"- 21° <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offslte Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />city/state/zip Undo-) (.11 '1523 6 Phone (1.0(1)8$1. -230o <br />APN <br />(2.5-6) -5‘0 - 2%45 Phone (1.5.0 353 - 6'8 113 <br />License!, -4 402 5g Phone (I14) q 04/02. <br />City/State/Zip Scovt-.. fe.. Spings, CA 106(3-0 <br />licenseit CIZ Phone (115) - Ef5.1 <br />City/State/Zip Say, Ock t-rioin , CA. f <br /> 0 MUD ROTARY <br />3 El PUSH POINT (GP/ CPT) <br />0 INJECTION Or Spam. Ozone) 0 HAND AUGER <br /> <br />0 OTHER OTHERr <br />WELL/SOIL BORING IDs SBI ,Sf32.1 %65 <br />BORING DEPTH IS • 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE •ct . 0 MULTIPLE CASINGS ID MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS D HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Free/all Depth 1s30 Fl) <br />GROUT SPECIFICATIONS <br />0 MONITORING <br />0 EXTRACTION (Vapor/Water) <br />ID SOIL VAPOR PROBE <br />in SOIL BORING <br />El HOLLOW STEM <br />0 HAMMER/DRIVEN <br />DESTRUCTION WORK TO BE PERFORMED: <br />//WELLS TO BE DESTROYED <br />WELL IN <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED EJAUGERS DHOSE 1:1 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <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 />Signed --"/"-/iVi-, -----,.,-; Title/Company ?roje..(..-1- El-eUlOPP`St / AIL A 5 <br />Print Name MIChe, I 14- -1,e.rbe, Date 10 I 114 I 2.02.1 <br />DEPARTMENT USE ONLY <br />FA Narne BONNIES PLANTS FA Address 23975 E. MILTON FAil FA0026828 PR# PR0547253 <br />FA PE 2950 WP Reviewed By JW Work Plan Date 10/12/2021 <br />0 C-57 El C-57 Authorization for Others Sign Permit I=1 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval DI hIFR <br />X COMMENTS/CONDITIONS: <br />SUMB1T A COPY OF REPORT TO EHD PER WELL STANDARS 13.7.2 <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 2905 313 $152x 3 456 5350 JW 10/15/21 WP0049696 <br />SR0084390 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />El-ID 20-01 06-20-21 Slte Mitigation Well Permit Application