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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 530 North Stanislaus Street City/State/Zip Stockton/CA195202 Phone 209-460-5000 <br /> Cross Street East Fremont Street APN 139-224-090 r ri r�(� ) <br /> Property Owner' Gerald Jones of the Housing Authority of the County of San Joaquin ( Vlp 1^(Cc C AA f hone 209-460-5000 <br /> Address 2575 Grand Canal Blvd City/StalelZip StocktonlCA195207 <br /> C-57 Contractor TEG-Northern California License# 706568 Phone 116-853-8010 <br /> Address 11350 Monier Park PI City/Stale/Zip Rancho Cordova/CA/95742 <br /> Consultant/Sub-Contractor Condor Earth License# CA PG No. 9945 Phone 209.613.7634 <br /> Address 188 Frank West Circle, Suite I City/StatellZip Stockton, CA, 95206 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: O#site BoringsNJelis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5.5' ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERDRIVEN DIA.OF BOREHOLE 2.25' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ® SOIL VAPOR PROBE 2 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> ❑SOIL BORING 0 PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Rorirg Na: Caingga: Casing Depth: <br /> ❑ INJECTION fasaarae.omrial ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPETO BE USED: ❑AUGERS El HOSE aIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes❑ No (Note:Ma)dmum Freefall Depth is 30 FQ <br /> WELL/SOIL BORING ID; ASG-1 and MG-2 GROUT SPECIFICATIONS NealCementGrout <br /> � �� �f <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTIONGt� METHOD: (CHECK ALL THAT APPLY) T7(,lft0✓�� ��y� Tn. <br /> #WELLS TO BE DESTROYED ®OVER-BORE DIAMETER of 2.25 inches to depth of 5.5 feel <br /> WELL IDS ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: ASGA and ASG-2 will be destroyed pursuant to SJCEHD Well Standards <br /> I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br /> // //� nSan Joa��q/uin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed .L-z� C�d� Title/Company Associate Geologist/Condor Earth <br /> Print Name Luke Castle Date 4/2 312 02 4 <br /> DEPA MENTIANHONLY <br /> Application Accepted By: �LJ Date Issued: <br /> Grout Inspection BylDates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name ,9 FAAddrass jU t S 1 ',5 FA# 1 Q Q ZB !5 PR# (,') <br /> FA PE Z ` 7 Q WP Reviewed By Work Plan Date A 1­1102� <br /> 0C-57 G57AuI1wriralianfor Otherto Sign Permit ❑Worker`s Comp ❑Workers Gomp Waiver ❑Eneroachmem Peenil ❑Access Agreement ❑Lead Agency Approval MFR <br /> COMMENTS/ ONDITIONS: <br /> WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 3 $162xIf 1 CC lj Zlf- f 0� S <br /> CC # lfi I!, i3 � 5S� 5 008� `► � <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 J 209 464-01l§8 wwww.sjgov.org/ehd <br /> LED 2M106-28-21 Site Mifigafion Well Perrot Application <br />