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SAKJOAQUIN Environmental Health Department <br /> �t COUNTY— <br /> ; ,, ogre=ui'ne;; u�' rnlvs liar-e. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For Ali Inspections <br /> CALL (209) 963-7697 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 200 North Wilson Way City/State/zip Stockton, CA 95205 Phone N/A <br /> Cross street East Channel Street and East Miner Avenue APN 15303029 <br /> Property Owner- Singh Property Inc Phone N/A <br /> Address 4751 Tudor Rose Glen Road City/State/Zip Stockton, CA 95202 <br /> C-57 contractor Environmental Control Associates License# 695970 Phone (831) 662-8178 <br /> Address 3011 Twin Palms Drive citylstate/zip Aptos, CA 95003 <br /> ConsuitantlSub-contractor AEI Consultants License# 654919 Phone (408) 442-2605 <br /> Address 2500 Camino Diablo City/Statelzip Walnut Creels, CA 94597 <br /> CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite BodngsNVelis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA,OF BOREHOLE 2.25 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPEOFCASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes (ZNo Boring Ole: Casing Dla: Casing Depth: <br /> ❑ INJECTION Wrapaae.Ozone) 0 HANDAUGER GROUT SEAL DEPTH TREMIE IYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER M OTHER Direct Push GROUT SEAL PUMPED? [I Yes I@No (Note:MaAmum Freefall Depth Is 30 Ft) <br /> WEW SOIL BORING IDs $$-1 aril S$-2 ? O " ,f'F,jK GROUT SPECIFICATIONS Neat cement grout <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: tCHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED N/A ❑ OVER-BORE DIAMETER of_inches to depth of feel <br /> WELL Ds ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES Fromto feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑ MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work wdlrbe done in Accordancewttl. <br /> /f �J San Joaquin County Ordinance Codes and Standards and all other applicable California laws. <br /> Signed /T-///?�J Title/Company Project Geologist/AEI Consultants <br /> Print Name Natasha Eudimirovic Date 3/7/2024 <br /> ___ j µ DEPARTMENT USE ONLY ',. <br /> Application Accepted By: d-d Date Issued: �"�i� <br /> Grout Inspection By/Dates: ',. <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name h t'a - f a""l FA Address FA# ^� PR# FBI <br /> I <br /> FA PE Lzq 570 1 WP Reviewed By Work Plan Date 1, <br /> ❑G57 C-57 Aulhodzaflon for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval MFR <br /> COMMENTSICONDITIONS:-7 f,y � wa Tom Q wu— a&� <br /> 9 A. ! <br /> WP TYPE I SC FE INFO AMT REMITTED CHECK# R CV'D BY DATE WELL PERMIT# INVOICE# <br /> permit Ql 1fl $156x `� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 ( T 209 468-3420 1 F 209 464-01 Wgcthfd`om <br /> EHD 29-01 04-20-23 py � site Mitigation Well Permit Applipgon 1 <br /> -17 bL-,furl 15, e `® Jl&�a'`" Vf P-swvzw;Iiry I <br />