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SA N J 0 A Q U I N Environmental Health Department _..._..._C0U NTY- SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For Ali inspections CAI._I.. (269) 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 lo/(o S, (,,)e Is0/1 �_ )C_ 1 Clty/State/Zip, tt6t_kibA CA Phone Cross Street .AAe!sov, APN Property Owner* Phone Address City/State/Zip SApc EAssA CA gj_4Du5' C-57 Contractor f CA, "E,N(_, License# Phone Address 3C)II � �„n pj�(,AI�{ DC City/State/Zip A• ±0_1 CA 1S'ac.->3 Consultant/Sub-ContractorA m ,�,ky,-NAyA4. rltli d;C�� License# S;3!C;-=1 P. 4. Phone Address66?C5 ?-/kAA7X,,A.k- ct- A"-kr (o City/State/Zip C.hic—,5 CfA g<T a(, CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ___❑ HOLLOW STEM BORING DEPTH Sal-f i ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) _ ❑ HAMMERrDRIVEN DIA,OF BOREHOLE 6 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER SOIL BORING � ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Au Saarae.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER JZ OTHER:n_ GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth Is 30 Ft) WELL'SOIL BORING IDs 5 F,.,2 ��?y t.1 GROUT SPECIFICATIONS 1- L-eLV-1m DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑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: I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed C Title/Company()� E14 �ilI)i tpna,tA, t)'Lt_S Print Name 1✓jQ 5[�✓1 �ao l L�D _ Date 3— 3 - r}G DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Faciti /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Camp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: 4 WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# R C 'D BY DATE WELL PERMIT# INVOICE# Permit ,j $179 x i ( y W r1 6 IB 15 3 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4f8-3420 1 IF ^^" ....0138 1 www.sjcehd.com EHD 29-01 07-01.2025 _fit k� �y� ,% 1 Site Mitigation Well Permit Application