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- SAN ��AQ�11N ;:'�: C�UNiY ��.. '`� Greatness gro�,4s 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 1020 Dr Martin Luther King Jr Blvd Cross Street S Aurora St Property Owner* Kenneth Horton Address 6987 Pezzi Rd C-57 Contractor Cascade Drilling, Rick Alcartado Address 3459 Collins Ave Consultant/Sub-Contractor Address City/State/Zip Stockton, CA 95205 APN 16902004 City/State/Zip Stockton, CA 95205 License# 1058336 City/State/Zip Richmond, CA 94806 License# City/State/Zip Phone Phone 209-481-6918 Phone 510-478-0858 Phone CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsA/Vells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 26 feet (45 max) ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 Inch ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS ❑x SOIL BORING _2 _❑ PUSH POINT (GP/CPT) CONDUCTOR CASING ❑Yes ❑ No ❑ INJECTION (Air Sparge, ozone) ❑ HAND AUGER GROUT SEAL DEPTH ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? WELL/ SOIL BORING IDs 16 -B1 -SO, 16 -B2 -SO GROUT SPECIFICATIO Neat cement DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE COMMENTS: Signed ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER Boring Dia: Casing Dia: Casing Depth: TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE (N�te: Maximum Freefall Depth is 30 Ft) � �. ._s ...w ... uw1n rri it _� .AM 1 DESTRUCTION METHOD: (CHECK ALL THAT APPLY) � IR ❑ OVER -BORE DIAMETER of inches to depth of feet QI' ❑ PRESSURE GROUT To depth of feet below surface � v,� ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet DPT drilling of two 26 -ft deep soil borings for environmental soil and groundwater grab sampling (no well installation). One boring drilled to reach groundwater (max 45 ft deep if required). Analysis to include VOCs, SVOCs, TPH-GRO, TPH-DRO/RRO, CAM-1�- I hereby certify that I am authorized to complete tHFs application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. �� q Title/Company Regional Manager/Cascade Drilling Print Name Dustin King Application Accepted By: Grout Inspection By/Date Destruction Inspection By/Dates: Facility/Site Information_ Date 6.24.22 D ARTMENT USE ONLY Date Issued: s. ri FA Name ' �� FA Address G FA# 0 �=�-Z� PR# OtJ� FA PE WP Reviewed By J Work Plan Date � Zo C-57 ❑ C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Perm' Ac ss Agreement ❑Lead Agency Approval MFR COMM NTS NDITIONS: ��` � � n �.3 �� ,Z � 1� ��J ,�� � � � � n �� r � � ova r� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY D TE WELL PERMIT# INVOICE# Permit �� '®� $15 �� fpo 6 �' 3 � ✓ fit, l0'?� �-6 3 O �i� � �� g�� 1868 E. Hazelton Avenue � Stockton, alifornla 5�3 I T 2� 46�-3420 I F 209 X84-0138 � www.s�c�d.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application I