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PSull, <br /> U C' <br /> SA N J O AQ U I N Environmental Health Department <br /> —COUNTY— j <br /> _.cicn.ons�; Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y� <br /> 24 Hours Advance Notice Required For All Inspections !may <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 18045 S. Kelso Road City/State/Zip Mountain House,CA, 95391 Phone t209}831-5648 <br /> Cross Street Kelso Road and Byron Road APN 258-020-29 <br /> Property Owner* Mountain House Community Services District Phone (209}831-5648 <br /> Address 251 East Main Street Clly/StetelZip Mountain House,CA,95391 <br /> C-67 Contractor Greg Drilling, LLC License# 1044466 Phone (925)313-5800 <br /> Address 2100 Goodyear Road City/State/Zlp Benicia,CA 94510 <br /> ConsultantfSub-Contractor California Department of Water Resources License# NIA Phone (916)653-5791 <br /> Address 715 P Street City/StatelZip Sacramento,CA,95814 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELLIBORING UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 4,nested HOLLOWSTEM BORING DEPTH 650 ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VapaNyal ) HAMMERNRNEN DIAL OF BOREHOLE Is',t+ k. wIr-a' ®MULTIPLE CASINGS[I MULTREVELWELL CASING DIA 2.5 Inch,SCH 60 <br /> ❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS Bob.80 PVC TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPf) CONDUCTOR CASING ❑Yes ®No Bang Dia16',ie., .12'.Bbming Dia: 2.6' Casing0eph: (seedrawing) <br /> ❑ INJECTION Inlrsolocomres ❑ HAND AUGER GROUTSFALDEPTH TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEALPUMPED? Wyss []No (Note:Maximum Freefall Depth is 30 Fit <br /> WELUSOILBORING IDs GROUT SPECIFICATIONS 10.3 sack neat cement <br /> DESTRUCTION ORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLY) <br /> #WELLS TO BE DESTROYED El OVER-BORE DIAMETERef_Inchestodepth of feet <br /> WELL Me ❑PRESSUREGROUT To depth of feet below surface <br /> GROAT SPECIFICATIONS [I EXPLOSIVES From_to_feat below surface <br /> TREMIETYPETO BE USED [I AUGERS [I HOSE [I PIPE [I MUSHROOM CAP ❑3 feel belay surface or—feet belowsudace 11>3 feel <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> �,�/J� San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed -ZSNQ Title/Company Greggainmg,LLC <br /> Print Name mm Boyd Date August e,2m4 <br /> �1­999ARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Date . <br /> Destruction Inspection By/Dale : I I1k110i1 VjaS l END VJM not a6tM* for -Mt Uf(hrm N q'�r��tC. <br /> aclllt /Site Information ' {" was h wa (i 12 wov h{C <br /> FA Name Ago, FA Address S Q FA# PRO bbKtbh1�15 wat <br /> FA PE WP Reviewed By Work Plan Gate 1 b 2 ldyu 2�D <br /> p2))u,+ ih <br /> 4,57 ❑C57A71hodabonforOtherioSigniselml ❑WahersCcmp ❑W~sCanpWaMa ❑EncroachmemPermit ❑AccessAgreemeM AaexyAWWal XMI �j1)rCoran <br /> ' COM ENTS/CON TIONS; hf G r PP.ros OI ;tlSPC� � � x <br /> rade� /n �Eor ,s se eJ- GtMrIwto sals,. a a� tea U <br /> O i N 1 B M F ' C n FrcU�a o e'f, L <br /> JWPTYPEJ PE I SC FEE INFO AMT REMITTE CHE RECV'D BY DATE WELL P RMIT# INVOICE# <br /> Permit o < t�i.` +s16 4 1 <br /> 1868 E. Hazelton Avenue I Stockton California 95 05 LLLT 209 468-3420 1 F 209 464-0138 n .sjceh <br /> EHD Mot g4-2a-23 j8 ;'b 111 }Lt �yID) Site Miagatim M11 P-rulApplra9on <br /> ( -V ) IgS 00Z99Z Icy <br />