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SAN JUAUUIN <br />V COUNT <br />Greatness grows here. <br />Environmental Health Department <br />SITE MITIGATION WELL Ot 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 321 S Union St <br />Cross Street E Sonora St <br />Property Owner* Alfonso Ocampo <br />Address 1036 E Sonora St <br />C-57 Contractor Cascade Drilling, Rick Alcartado <br />Address 3459 Collins Ave <br />Consultant/Sub-Contractor <br />Address <br />City/State/Zip Stockton, CA 95205 <br />APN 15126004 <br />City/State/Zip Stockton, CA 95205 <br />License# 1058336 <br />City/State/Zip Richmond, CA 94806 <br />License# <br />City/State/Zip <br />Phone <br />Phone N/A <br />Phone 510-478-0858 <br />Phone <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 11 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />El SOIL BORING 2 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED. ❑ Yes ❑ No Note: Maximum Freefall Depth is 30 Ft <br />� x ( P ) <br />WELL/ SOIL BORING IDs 8 -131 -SO, 8 -132 -SO GROUT SPECIFICATIONS Neat cement >,�,rn�AM jO l('�.z/a r / <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS ❑HOSE ❑'PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of 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 />COMMENTS: DPT drilling of two 11 -ft deep soil borings for environmental soil sampling. <br />Analysis to include TPH-GRO, TPH-DRO/RRO, CAM -17 metals <br />1 hereby cert <br />ify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Regional Manager/Cascade Drilling <br />Print Name Dustin King Date 6.24.22 <br />D PARTMENT USE ONLY <br />Application Accepted By: ( Date Issued: � Z� �� <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: Z <br />Facility/Site InformationLK <br />FA Name FA Address G n, FA# � Q Z,?�w <br />LLI <br />Z <br />PR# <br />d <br />� - <br />FA PE <br />WP Reviewed By <br />�� <br />Work Plan Date <br />C 57 ❑ C-57 Authorization f r Other to Si n Permit <br />❑ Worker's Comp ❑ Workers Comp Waiver ❑ Encroachment Permit <br />Access Agreement ❑ Lead Agency Approval <br />PKIR <br />COM O! tD T! IONS: <br />dCOO <br />C L[(� <br />GTj!/ <br />M�S� i11Z a 4. <br />'5 <br />&V4% S� <br />WP TYPE <br />PE SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV-'D. BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />aO <br />$1 <br />D <br />1 oo L3 ,S <br />1868 E. Hazelton Avenue <br />EHD 29-01 04-04-07 <br />Stocktoorn <br />n, allfia 95 5 209 468-342 � F 209464-0138 www.sj d.com <br />Site Mitigation Well Permit Application <br />