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SANsJOAQUIN Environmental Health Department <br /> —COUNTY— <br /> c <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 306 North Ham Lane chy/Stata/zip Lodi, CA 95252 Phone <br /> cross street West Lockeford Street APN 037-10-030 <br /> Property Owner• Stone Brothers &Associates (John Godi) Phone 209-200-8506 <br /> Address 1036 West Robinhood Drive, Suite 202 chy/statelzip Stockton, CA 95207 <br /> a57eontrapeorEnvironmental Control Associates (ECA)Licenae$ 695970 Phone 831-662-8178 <br /> Address 3011 Twin Palms Drive City/state2lp ADtos. CA 95003 <br /> COnsultanVSub-Contractor License$ Phon <br /> Address Zwt2 .A} -f� o k tate2lp L B <br /> CONSTRUCTION WORK TO BE PERFORMED,'Note: OgsQe BoringsWells Require Access Agreements or EncroachmentPermits DO) <br /> TYPEOFIVELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ElMIN110MNG ❑ HOLLOWSTEM BORING DEPIH B 6TM ❑BOLTEDTRAFHCWX ❑STOVEPIPE <br /> ❑ EIITRCTDN(Vac0slal ❑ IUMMERIDRIVEN 13MULTIPLECASINGR13MULTLLEVELWELLCSINGDN <br /> D(WILVAPORPROBE 4 13 MUDROTARY CASING TiDIMESR TYPEOF CARING:135 13M El OTHER <br /> X SULBORING 4_13. R,SHPOINT(GPICPD CONDUCIORQVIING ❑Yes 13NO WAm me Cednp Da Gem,Deph: <br /> ❑ INJECTION u,auw.a ❑ HANDAUGER GROUTSEALOEm TREMIETYPETOBEUsax 13AUGEas 131105E 13RPE <br /> ❑ OTHER ❑ OTHER SPECGROUTSEALPJMPED2 ❑Y.13Ns (Nate:Maa pNM30N I <br /> w11UMILEDRINGIN �B�1-B4— GROIrt IRCATIONS Neat cement grout vi bemm:Welllsail vapor probe sand �PO DQIakJ <br /> Packlecuipment WIII be ftsmovEl before grouting <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECKALLTHATAPPLYI <br /> $WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of Renee to depthof feet <br /> WELL IOs ❑PRESSURE GROUT Tatlephof featiamsudaca <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES Fmm_to_faetbelassurime <br /> TREMETYPE TO BE USED [I AUGERS ❑HOSE [I PIPE ❑MUSHROOM CAP ❑3 fast Islow slsfsw or feet belaveurfice N>3 feat <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 9* I,25s d TitleJCompany Project Manager/Partner Engineering&Science, Inc. <br /> Print Name MiQhel Helou Date 5/5/2023 <br /> DEPARTMENT USE ONLY LL <br /> Application Accepted By: Date Issued: <br /> Grout Inspection ByWates: <br /> Destruction Inspection By/0ates: <br /> Faclli /Site Information <br /> FA Name O flTA I FAAddress 3o N , FA$ I ooZ PR# orjf(-g Ll-3" <br /> FA PE WP Revieaed By work Rai OeN 1 S-/5-/ ,20`.�,3 <br /> ❑OR AVRodte9mftoOBeftpslpn Famit ❑Wp,Mrs Comp 13MbAsfs Dunp Wdwr ❑EnaoeAnenl PemRoiscissAgmarat DWAgnsAulneolM <br /> COMMENTS/ ONDIT1ONs: QY'r'wry rNC sot a fors probes aF PA4 a-,K yyTa}, rna •' <br /> dopl�be-�r2 P A/�G, ta�L Ar1 <br /> Ns-2' ozw�lw— 1 �In. -� i m 4 O a.F / d' to <br /> IWTYPEI <br /> ppPE SC I FEE INFO ANIT REMITTED CHECK$ REWDB D TE WELL PERMIT$ INVOICE$ <br /> Permit ZIP 313 $+�X C S0 oo �F � <br /> a 4 <br /> 1888 E. Hazelton Avenue SP-pc %Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 vim.sjcelid, <br /> EHD29,01M 3 ^c - ' / 11[j 'L lr-q -') as.Mltlwdm was Pe,ml1APJIVetlon <br />