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SAN JUAQUIN COU NTY�- Grrntness grows harp. Environmental Health Department SITE MITIGATION WELL ot 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 Cross Street 1206 E. March Ln. West Lane Property Owner* City/statelZip Stockton, CA 95210 Phone APN 104-160-04 3< .00 — 2 Oqp BP West Coast Products LLC/Shell March Lane Address PO Box 941709 C-57 Contractor Cascade Drilling City/State/Zip Houston, TX 77094-8709 License# 1058336 Phone Address 3000 Duluth Phone city/state/zip West Sacramento, CA 95691 St. Consultant/Sub-Contractor ATC Group Services LLC dba Atlas Technical License# Address 1117 Lone Palm Avenue, Ste, 201 B City/State/Zip Modesto, CA 95351 916-638-1169 Phone 209-579-2221 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WPI LIBORING NUMBER ❑ MONITORING ❑ ❑ EXTRACTION (VapodWater) ❑ ❑ SOIL VAPOR PROBE ❑ ❑ SOIL BORING ElElINJECTION (Air Sparge, ozone) ElElOTHER ❑ WELL/ SOIL BORING IDs INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 18 ®OVER -BORE DIAMETER of 2-8 inches to depth of 5-80 feet WELL IDs see comments below ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ® AUGERS ElHOSE ❑ PIPE ElMUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENT& Well Ids: MW -1, MW -2, MW -3, MW -4, MW -5, MW -6, MW -7, MW -11, MW -12, MW -13, MW14 AS -1, SVE-1, SVE-2, SVE-3, VP -1, VP -2, VP -3 0 K +o desk Mui tf b mss _ _ I hereby certify that I am authorized to complete this application and that th06 work will be dohe in accordance San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. j Signed tle/Company RE Tonal Manager Print Name US In win - Date 6.22.22 " DEPARTMENT USE ONLY w,,, l2� �zo 2 Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/[ 2 Facilitv/Site Information 5 FA Name S � dy� FA Address � �Q a FA# /%n FA PEJ/ P 2 WP Reviewed By �% Work Plan Date jT'" 7 pZZ C-57 ElC-57Authorization for Other to Sign Permit El Workers Comp ❑ Worker's Comp Waiver ElEncroachment Permit ccess Agreement Lead Agency Approval ElMFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE ,i AAQWELL PERMIT# INVOICE# Permit on VJ L $152 x !}' 243 q 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA, OF BOREHOLE ElMULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL El PVC [IOTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING [IYes ElNo Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [IAUGERS [IHOSE ElPIPE OTHER: GROUT SEAL PUMPED? ElYes ElNo (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS s PLO o$5741'1-- 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA, OF BOREHOLE ElMULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL El PVC [IOTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING [IYes ElNo Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [IAUGERS [IHOSE ElPIPE OTHER: GROUT SEAL PUMPED? ElYes ElNo (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS s PLO o$5741'1--