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SAN �J 0 A Q U I N Environmental Health Department <br />"COUNTY <br />CL.4 Greofness 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 1503 E. March Ln. <br />Cross Street West Lane <br />Property Owner` Gill Medical Center, LLC <br />Address P.O. Box 1450 <br />C-57 Contractor Cascade Drilli <br />City/State/Zip Stockton, CA 95210 Phone _ <br />APN 096-140-38 0 0Z� — 12�Z°(04() <br />Phone <br />City/State/Zip Lodi, CA 95241 <br />License# 1058336 Phone 916-638-1169 <br />Address 3000 Duluth St. city/State/Zip West Sacremento, CA 95691 <br />Consultant/Sub-Contractor ATC Group Services LLC, dba Atlas Technical License# Phone 209-579-2221 <br />Address 1117 Lone Palm Avenue. Ste. 201 B <br />City/State/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING <br />❑ MONITORING <br />❑ EXTRACTION (VaporlWater) <br />❑ SOIL VAPOR PROBE <br />❑ SOIL BORING <br />❑ INJECTION (Air Soaroe.Ozone) <br />❑ OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ <br />HOLLOW STEM <br />BORING DEPTH <br />❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />❑ <br />HAMMER/DRIVEN <br />DIA. OF BOREHOLE <br />❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ <br />MUD ROTARY <br />CASING THICKNESS <br />TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ <br />PUSH POINT (GP/ CPT) <br />CONDUCTOR CASING <br />❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ <br />HAND AUGER <br />GROUT SEAL DEPTH <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ <br />OTHER: <br />GROUT SEAL PUMPED? <br />❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />Agreement ead Agency Approval <br />COMMENTS/CONDITIONS: <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 1 <br />WELL IDs MW -16R <br />GROUT SPECIFICATIONS neat cement <br />TREMIE TYPE TO BE USED ® AUGERS ❑ HOSE ❑ PIPE <br />COMMENTS: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />® OVER -BORE DIAMETER of 8 inches to depth of 55 feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed ,tit, Title/Company Regional Manager <br />Print Name Dustin Kinch Date 6.22.22 <br />4A • S� DEPARTMENT USE ONLY /7 �/Z7O <br />Application Accepted By:A�'/AV� Date Issued: �i <br />Grout Inspection By/Dates: v <br />Destruction Inspection By/Dates: <br />Pnrilifv/Sita Infnrmnfinn <br />FA Name <br />FA Address <br />j ZD6FA# <br />2,;� q -q <br />PR# <br />p 9-7-2 <br />FA PE <br />/�C( <br />o <br />WP Reviewed By <br />W <br />Work Plan Date <br />Ze <br />57 ❑ C-57 Authorization <br />for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permitccess <br />Agreement ead Agency Approval <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />PE <br />Sc <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# INVOICE# <br />Permit <br />W� <br />$152 x <br />Z <br />`3 � <br />b /Z,3 14Z. <br />V11>oo y <br />2 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />