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SAN JUAUUIN C QU NTY Greatness grows here. Environmental Health Department 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 1015 E Market St Cross Street S Union St Property Owner* Alfonso Ocampo Address 4408 Carpenter Road C-57 Contractor Cascade Drilling, Rick Alcartado # 1058336 Address 3459 Collins Ave Consultant/Sub-Contractor Address City/State/Zip Stockton, CA 95205 ApN 15120209 City/State/Zip Stockton, CA 95215 License City/State/Zip Richmond, CA 94806 License# City/State/Zip Phone Phone N/A Phone 510-478-0858 Phone CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ❑ MONITORING ❑ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ElEXTRACTION (Vapor/Water) ❑ El SOIL VAPOR PROBE ElE SOIL BORING 2 ❑ [:1 INJECTION (Air sparge, Ozone) ElElOTHER ❑ WELL/ SOIL BORING IDs 1 -B1 -SO, 1 -B2 -SO HOLLOW STEM BORING DEPTH 11 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA, OF BOREHOLE 2.25 inch El MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL El PVC El OTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes El No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS El HOSE El PIPE OTHER: GROUT SEAL PUMPED? ❑ Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS Neat cement DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP Fl3 feet below surface or feet below surface if >3 feet COMMENTS: DPT drilling of two 11 -ft deep soil borings for environmental soil sampling. Analysis to include TPH-GRO, TPH-DRO/RRO, CAM -17 metals I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed ��o � , Title/Company Regional Manager/Cascade Drilling Print Name Dustin King Date 6.24.22 DEPARTMENT USE ONLY FL2 Application Accepted By: Date Issued: Grout Inspection By/Dates: e Destruction Inspection By/Dates: �2i W40 o 'ZZ Facility/ ite Information FA Name FA Address � Lhetn FA# QQ _ PR# id FA PE WP Reviewed By Work Plan Date � AAA� 2 1868 L. lazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sj ehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application Z -57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit 44.C.Cess Agreement ❑ Lead Agency Approval FR COMM NTS/CQONDITIONS:�� l (r Vi Per ✓J C-�- ,�,�� j'� µ�� a J� � � p V 0i � W TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit 3 $15 14 8 Wpoo zo 5 LI L 1868 L. lazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sj ehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application