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SAN JUAUUIN <br />C QU NTY <br />Greatness grows here. <br />Environmental Health Department <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 1015 E Market St <br />Cross Street S Union St <br />Property Owner* Alfonso Ocampo <br />Address 4408 Carpenter Road <br />C-57 Contractor Cascade Drilling, Rick Alcartado <br /># 1058336 <br />Address 3459 Collins Ave <br />Consultant/Sub-Contractor <br />Address <br />City/State/Zip Stockton, CA 95205 <br />ApN 15120209 <br />City/State/Zip Stockton, CA 95215 <br />License <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 <br />❑ MONITORING ❑ <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ElEXTRACTION (Vapor/Water) ❑ <br />El SOIL VAPOR PROBE ElE SOIL BORING 2 ❑ <br />[:1 INJECTION (Air sparge, Ozone) ElElOTHER ❑ <br />WELL/ SOIL BORING IDs 1 -B1 -SO, 1 -B2 -SO <br />HOLLOW STEM BORING DEPTH 11 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMER/DRIVEN DIA, OF BOREHOLE 2.25 inch El MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL El PVC El OTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes El No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS El HOSE El PIPE <br />OTHER: GROUT SEAL PUMPED? ❑ Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Neat cement <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑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 Fl3 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 />I hereby certify 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 />Signed ���o � , Title/Company Regional Manager/Cascade Drilling <br />Print Name Dustin King Date 6.24.22 <br />DEPARTMENT USE ONLY FL2 <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: e <br />Destruction Inspection By/Dates: �2i W40 o 'ZZ <br />Facility/ ite Information <br />FA Name FA Address � Lhetn FA# QQ _ PR# id <br />FA PE WP Reviewed By Work Plan Date � AAA� 2 <br />1868 L. lazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sj ehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />Z <br />-57 <br />❑ C-57 <br />Authorization <br />for Other to Sign Permit <br />❑ Worker's Comp ❑ Worker's Comp Waiver ❑ <br />Encroachment Permit <br />44.C.Cess Agreement ❑ Lead Agency Approval FR <br />COMM NTS/CQONDITIONS:�� <br />l (r Vi <br />Per <br />✓J C-�- ,�,�� <br />j'� µ�� � a J� � � <br />p V 0i <br />� <br />W TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />I RECV'D <br />BY <br />I DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />3 <br />$15 <br />14 8 <br />Wpoo zo 5 LI L <br />1868 L. lazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sj ehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />