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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> •c"<rodr� 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 consbllct and/or Install the work described. <br /> This application is made in compliance with San Joaquin County Development Tille,Chapter 9-1115.3. and the San Joaquin County Well Standards. <br /> Job Address 602 N. California St. City/State/Zip Stockton,CA 95202 Phone 209464-1282 <br /> Cross Street Oak St. APN 139-165-09 <br /> 209-4366022 <br /> Property Owner' Gary SlaR.vorlh Phone _ <br /> Address 1107 Burkell Ave. CitylState/Zlp Stockton,CA95205 <br /> C-57 Contractor TEG License# 708568 Phone 916-853-8010 <br /> Address 11350 Monier Park Place City/State/21p Rancho Cordova,CA 95742 <br /> ConsultantfSub-Contractor Ground Zero Analysis License# PG 6023 Phone 209-6224119 <br /> Address 1172Kansas Ave. City/State/Zip Modesto CA 95351 , <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: ONsile Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTALLA71ON TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH _6-10R ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor7Wateq ❑ HAMMEWORIVEN Dal OF BOREHOLE -1 Inch ❑MULTIPLE CASINGS MULTREVELWELLCASWG DIA <br /> 0 SOILVAPORPROBE 2 ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 0 SOIL BORING 1 0 PUSH POINT(GP/CPT( CONDUCTOR CASING ❑Yes [3 No Baird DO: Casing Dla: CasYq Depth <br /> ❑ INJECTION Iarsas,omat ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED. [3 AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSFALPU <br /> ❑ ❑ ,admnF fatDthh30Fg <br /> N QWEWSOILBORINGIDs VP-1,VP-2,24-$84 GROUT SPECIFICA ss�r -S,IpsAA <br /> �2rd w, <br /> DESTRUCTION WORK TO BE PERFORMED- 0 R I OD• L HATAPPLYIrvV.� <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_klehes to depth of feett ��� � <br /> WELL IDs ❑PRESSURE GROUT To depth of__feet below surface a <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES Front_b—feelbelowsudace <br /> TREMIE TYPE TO BE USED ❑AUGERS HOSE [I PIPE ❑MUSHROOMCAP ❑3 feetbelow surface or feet below sudace 1>3 feet <br /> COMMENTS: <br /> 12/27/23 Workplan appr ved by RWQCB <br /> Therein ertify thetl a "lauthqdW to complete this application and that the work will be done In accordance with <br /> San Joaqul a des and Standards,and all other applicable California laws. <br /> Signed TIBelCompany Ground Zero Analysis,Inc. <br /> Print Name Gregory Stewv r Date May 14,2024 <br /> DEPARTMENT SE O LY c /F <br /> Application Accepted By: - Date Issued: _ ✓ ,LB <br /> Grout Inspection By/Dates:- Z <br /> Destruction Inspection By/Dales: <br /> 4 N Y4 qJ Tn aA, <br /> FA Name (A/d FAAddress ' CL` FA# PRO 0.t� <br /> FA PE 4 o wP Reviewed By Work Plan Dale Z � -7 . z�Vj. <br /> �� <br /> ❑047 in <br /> At"turtonforOlhertoSlpnPeimh ❑WokersComp ❑WakeesCompWaNer 1311mmachmenlPermlt ❑Aaeas Agreement ad Agency R <br /> COMMENTS OND TIONS: S u .A( ` ]0 <br /> �jY- <br /> wPTyPEj PE I SC I FEE INFO JAMT REMI ED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit lO t $162X C / _ Z3 WP 2 3 $ <br /> t &1 W2;16Lkyf R Vt <br /> 1868 E. Hazelton Avenue I Stockton, Callforn a 5205 I T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2%0I 7-01.2023 elm Miegaean Wolf Pama AWl"Im <br />