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SA N 10AQ U I N Environmental Health Department COUNTY SITE MITIGATION WELL & BDRM PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections C AV ?-400 & 5 5 CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work 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 City/State/Zi n1A CJGZaPhon, Cross Street r Wag APN Property Owner* (/C� i Phone Address r City/State/Zip C-57 Contractor r { License# ..1-26rMPhone J3V M -3t7fJ�� Address F City/State/Zip {6 ??�� '/ G Consultant/S/uubb-Contractor License# Phone V&U2�y%Z9 Address 1 ,es Z 09611 S City/State/Zip As�WJe q, 2� CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: t ❑ INJECTION(Air Soarge.0zonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 7 OTHEROiCtC OTHER: 1 ti GROUT SEAL PUMPED? ❑Y D No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs -01 GROUT SPECIFICATIONS (Y))I/re- W- N DESTRUCTION WORKBE PERFORMED: U 1� h dESTRUCTION METHOD:(CHECK ALL THAT APPLY) Gc #WELLS TO BE DESTROYED "A ❑OVER-BORE DIAMETER of inches to depth of feet C e WELL IDs i ❑PRESSURE GROUT To depth of feet below surface ho rAare +kqn t GROUT SPECIFICATIONS El EXPLOSIVES From to feet below surface / ht TREMIE TYPE TO BE USED ❑AUGERS El HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface 9>3 feet CO MENTS: �:Sc"ij 6vrIrt55 cxn6 ti,rre.� Lo -+ter SAthQe-3 -W! Cb- Wi Sn 5 ¢ 1tZ" O�CG<Ghoj e-f`. .. 1 (''�!v r . e'•e..v f �� t - 3 ✓A?' ✓ ('czJC. �1' r-. Pia4'-r/ ' � I hereby certify that I am authorized to complete this application and that the work wiff be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company p �66 Qfii M tAn�S-(-1 Porll CWc p/'1 Print Name, Qlq/t Gl -7 re6'?, Date / 'Z!-Z l,( J DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date j- ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval GI MFR COMMENTS/CONDITIONS: "( A-6(mo 60" -A r"c(mod i A' t tM� t'q yr' a; �N s c,�{i M , P f� ;.SL c.�o :5 b;ll4l too P'r- Mt=R 5 L'Ot jfNic, ml 4 cL Y-1 c'li:'r" ✓r sti l' tMA -'v ' WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE rW{E.LL PERMIT# INVOICE# Permit ^ r `�jt� x ,; .,� ( ' J V 1 .1'37- 11= t L. t 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3a90 I F 209 464-0138 1 www.sjcehd.com EHD 29-01 7-01-2023 `-�- `v p � w.k;.E;^ �y r j�U. , .. �� ty arse Mitigation Well Permit Application r I j