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SAN JOAQUIN COUNTY 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 2085 E. Main Street Cross Street C Street City/State/Zi p Stockton, CA 95205 APN 153-102-100-000 Phone N/A Property Owner* City of Stockton ROW Phone Address 4 Centerpointe Drive, Suite 200 City/State/Zip La Palma, CA 90623 C-57 Contractor Cascade Drilling LP License# 1058336 Phone ROI Address 3000 Duluth St Antea Group Address 11010 White Rock Rd, Suite 140 West Sacramento95691 CitylState/Zip , CA License# 0116983 Phone City/State/zip Rancho Cordova, CA 95670 (360) 594-7978 (707) 378-3768 (763) 453-0183 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ❑ MONITORING ❑ ❑ EXTRACTION (Vapor/Water) ❑ ❑ SOILVAPORPROBE ❑ ❑ SOIL BORING ❑ ❑ INJECTION (Air Sparge, ozone) ❑ ❑ OTHER ❑ WELL/ SOIL BORING IDs INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA, OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 � OVER -BORE DIAMETER of a.25 inches to depth of 45 feet WELL IDs MW -1, MW -2, and MW -4 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat cement (47 Ib bag/3.5 gal water) ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE 0 PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: Site has recently ended public comment period and is eligible for case closure. Three on-site wells of similar construction. Signed I hereby certify that I am authorized to complete this application and that the work will be done in accordance with ' San Joaquin C ��rdinance Codes and Standards, and all other applicable California laws. Title/Company Antea Group Print Name Regina Bussard � Date 8/1/2022 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Ak? 41 Date Issued: O `L 022 FA Name CoM,-yrww,��.� I'f�b5182�� A oC� 2. 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 46;-70138 1 www.sj �,� FA Atltlress � $� a � FA# Q �Z FA PE �74 WP Reviewed By � � e) Work Plan Datg5 � C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement Lead Agency Approval FR COM TS/CONDITIONS: WP TYPE SC FEE INFO AMT REMI CHnEC/K# RECV'D BY DATE WELL PERMITp# INVOICE# Permit QPE 0 1313 1 x� 3 f j,{.LQ 30 LtZ9 1 v(! lel. 0®�� 5 O cehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application