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Environmental Health Department =} SAN JOAQUIN p 11 { ) COUNTY Greatness grows here . SITE MITIGATION WELL & BORING PERMIT APPLICATION NON - REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL ( 209 ) 953 =7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described . This application is made in compliance with San Joaquin County Development Title , Chapter 9 - 1115 . 3 , and the San Joaquin County Well Standards , Job Address 1502 E . March Ln . City/State/Zip Stockton , CA 95210 Phone Cross Street West Lane APN 096 - 140 -2400 I C1 41 — 0 . Z011 �`� Property Owner* King of Central Valley Il , LP Phone Address PO Box 1547 City/State/Zip San Ramon , CA 94583 C -57 Contractor Cascade Drilling License# 1058336 Phone 916 .638 . 1169 Address 3000 Duluth St . City/State/Zip West Sacramento , CA 95691 Consultant/Sub -Contractor ATC Group Services LLC , dba Atlas Technical License# Phone 209 - 579 -2221 Address 1117 Lone Palm Avenue , Ste . 201 B City/state/zip Modesto , CA 95351 CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI- LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia : Casing Depth : ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED : ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No ( Note : Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED . DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED 1 ® OVER-BORE DIAMETER of 8 inches to depth of 55 feet WELL IDS MW- 15 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ® AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS : I hereby certify that I am authorized to complete this application and that the work will be done in accordance with Sal J aquin County Ordinance Codes and Standards , and all other applicable California laws . Signed �� A� Title/Company Regional Manager/Cascade Drilling Print Name Dustin King Date 6 . 22 . 22 DEPARTMENT USE ONLY Application Accepted By : 1A Date Issued : 6 ! Z -7 ko 2-� Grout Inspection By/Dates : A , 09 Destruction Inspection By/Dates : Facility/Site Information Ir r G1 7.2 FA Name (Sym FA Address Za FA# p p Z3 PR# FA PE ZGt > Q WP Reviewed By J Work Plan Date _1t7/Z.S7/Z0 C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker' s Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit cess Agreement Lead Agency Approva70 FR COM ENTS/CONDITIONS : WP TYPE PE I SC I FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit Zao 2, 13 #3 $ 152 x Z 15 0160, p Tom" 6 43Z2 I Lj 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 1 F 209 464 -0138 1 www . sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application