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i " SANAHON Department COUNTY— Environmental Health Greotness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections 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 521 North Cherokee Lane —City/State/Zip Lodi, CA 95240 ---rr /�� Phone (209) 601-6694 Cross Street Murray Street APN 421- - 6 VI+ I Z-r—T 5 7 Property Owner* Jose Garcia Phone (209) 663-6937 Address 3023 Woodson Road /(,Rrv/C4afn/71n Acampo, CA 95220 ry C57 Contractor CO-I /U 2V V'C'f7 VX Pi-eWp}7 Licensex /0�9/g Phone 916 - 77 D 'DD uTq Address /6-75 SuNrttSE s�)E'. . s v ire 33� City/State/Zip ,eDSPrn /fie 12A e/<-'o ? 0 Consultant/Sub-Contractor Stephen Muir Consult. g Geologist License# CBG 1224 Phone (209) 369-9421 Address PO Box 152 City/StatelZlp Woodbridge, CA 95258 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING IB HOLLOW STEM BORING DEPTH 20 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE IO inch❑MULTIPLE CASINGS MULTILEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER SOIL BORING PUSH POINT(GP/CPT) CONDUCTORGASING ❑Yes ❑No Boring Dia:10" Casing Dia: Casing Depth: INJECTION yorsoeree.Ozenel ❑ HANDAUGER GROUTSEALDEPTH 1 to 20' THEME TYPE TO BE USED: 15AUGEl25 [I HOSE ❑PIPE [I OTHER ❑ OTHER: GROUT SEAL PUMPED? (3 Yes [3 No (Note:Maximum Freefall Depth ls30 Fi) WELD SOIL BORING IDs SB23-1; -2; -3; -4; -5 GROUT SPECIFICATIONS 9-sack mix or as directed by SJCEHD inspector. 7T DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) -vte/s W^\Vr #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel WELL IDS ❑PRESSURE GROUT To depth of feel below sudace GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED []AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Five soil borings to 20 feet onsite. See Figure 1 for locations. After sampling is complete all borings will be b'ac�k"filled with grout mix as per SJCEHD inspector directive. Ar,rib'4?, Sox cJspi� 0.t'4- I hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with //,/ San Joaquin Count/yOnrdinance Codes and Standards,and all other applicable California laws. Signed 1�[ L ,��,.� i (��-r / " ICY'(-'"L/ Title/Company Stephen G. Muir Consulting Geologist Print Name Stephen/G.. Muir Date Augustllh, 2023 17l EPARTMENT USE ONLY 7 Application Accepted By: /� V v Date Issued: - 19 2 Q2 Grout Inspection By/Dates: H 4 Destruction Inspection By/Dates: Facilil ISlte Information IL FA Name lKirmar y�aCQ FAAddress 1 ,'5-, , /I7. C ,t ;e" FA# lao 2-790 1 PR# 0,1 FA PE VIP Reviewed By Work Plan Date . ❑C57 7Authodzallon Another to Sign Permit ❑Workers Comp DworkeesConipw'sW ❑Enwachment Permit ❑Axoss Agreement Agency Approval MFR COMMENTS/C NDITIONS:5U ( MIL , C&fY y-o np�.� Gor I s �� k� &-n o?t AA( Z / t ` IY 1 jWPTYPEj PE I SC I FEE INFO AMT REmi-riEDI CHECK# I RECV-D BY I DATE WELL PERMIT# I INVOICE# Permit , q,5 I q96P I 5LkG I Z911 I AM 19/G .3 Vv �oou4gi 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-01381'lwUVOiw sj'uehp-(,- dgCom EHO 29-01 04-20-23 Site Mitigation Well Pemit Application