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SAK OAQUIN Environmental Health Department`I —COUNTY— Greatness grows hat ,.. 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 Phone (209) 601-6694 Cross Street Murray Street APN MV/ Y oY 661)1 s7-R EtT CJt Property Owner* 1100e-19 - C,f Ph n F w i tic 1 L l5 e (26) 663-6937 one Address 3-029 Woodsori Itoaa nor s — ° a CA „59'0 gts` �yU )Jf /3JyA4 µ 3D '��ZeC57 Co 2antra o raa Phone AddressS p— city/StatelZlp Clovis: ( A 3 6i Z Consultant/Sub-Contractor Stephen G. Muir Consulting Geologist License# CEG 1224 Phone (209) 369-9421 Address PO Box 152 City/State/zip Woodbridge, CA 95258 6-5� CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits Dpy-. -54"ko� TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Muir m 4'lto/Zo2�. ONITORING E3 HOLLOW STEM BORING DEPTH PBOLTEDTRAFFICBOX ❑STOVEPIPE EXTRACTION(VaporAYaler) ❑ HAMMERARIVEN DIA,OF BOREHOLE —T�❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING CIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL.MPVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dla:10° Casing Cie: ;21" Casing Depth: '� -- ❑ INJECTION fPkSLaae.omna) ❑ HANDAUGER GROUT SEAL DEPTH —;j7� "5 TREMIETYPETO BE USED: WUGERS [I HOSE ❑PIPE Le/ 7r&M e 4 ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes �l+o (Note:Maumum Freefall Depth is�30 Fg rt r L a lie&4— WELL7SOILBORINGIDs WIN GROUTSPECIFICATIONS 9 saEk mix or as directed by SJCHHD inspector. Srve 4Trh t kEn MBA)b Wolf DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) �etg�a rNt If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL Ds ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑AUGERS QHOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet COMMENTS: .', �� e r.�/r. c �( ��c-r: Nrf �7A C G�ct y e.. nn ISI -�Q' Ynnt'2., Y1 jlZb0y" {rUrN �� M u t r✓2�X nc�C Cp fr Y knt z.✓N 61L t+�tGr z K c t it 1 hereby certify that I am authorized to complete this application arild that the work will be done In accordance with ' Sa/q'Joa�quin County Ordinance Codes and Standards, and all other applicable California laws. Signed t_I_td -,./.(A, , U • {'A v�•�` Title/Company Stephen G. Muir Consulting Geologist Print Name Stephen d. Muir Date DEPARTMENT USE ONLY (�/ZoZ4' n Application Accepted By: d Date I sued: .sC Grout Inspection By/Dates: Destruction Inspection By/Dates: F Illt She Information FA Name �t GLY Z tZ� FAAddress ,S �• C Ig robe FA# Z PR# O . FA PE 2— , i WP Reviewed By Work Plan Date f)L ❑G57 C57Authorizaibnfor Other Permit ❑Workels Comp ❑WOHeets Come p" ❑Erxm enlPermit ❑ memenl eadAgency Approval MFR COMMENTS/ NDITIONS: � �C I'Ctith A 7C a, iee vocrcbte, ,'-IrM;t5 ( �,� r 1.1 T-1- Ld-hj� WP TYPE PE SC FE NFO AMT REMITTED CHECK# RECV'D BY DA/ WELL PER T# INVOICE# Permit 040 -so s1 X 2 P„ lell 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 SWW�w.sjce d.Coin EHD 29-01 0E 20-23 Site Mitigation Well Pemit Application