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SAN JUAQUIN <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 1130 E. March Ln. <br />Cross Street West Lane <br />Property Owner* David C. Marshall <br />Address 124 S. Adams Dr. <br />C-57 Contractor Cascade Drilling <br />Address 3000 Duluth St <br />City/State/Zip Stockton, CA 95210 phone y <br />APN 104-160-31J01 <br />Phone <br />City/State/Zip Mt. Shasta, CA 96067 <br />License# 1058336 Phone 916-638-1169 <br />City/State/zip West Sacramento, CA 95691 <br />Consultant/Sub-Contractor ATC Group Services LLC, dba Atlas Technical License# <br />Address 1117 Lone Palm Avenue, Ste. 201 B <br />City/State/Zi Modesto, CA 95351 <br />Phone 209-579-2221 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ <br />ElEXTRACTION (Vapor/Water) ❑ <br />E]SOIL VAPOR PROBE ❑ <br />❑ SOIL BORING ❑ <br />ElINJECTION (Air Sparge, Ozone) ❑ <br />ElOTHER ❑ <br />WELL/ SOIL BORING IDs <br />HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMER/DRIVEN DIA. OF BOREHOLE ElMULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: ElSTEEL El PVC ElOTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING ElYes ElNo Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ElHOSE ElPIPE <br />OTHER: GROUT SEAL PUMPED? ElYes ElNo (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED 2 <br />WELL IDs MW -8, MW -9 <br />GROUT SPECIFICATIONS neat cement <br />TREMIE TYPE TO BE USED ® AUGERS ElHOSE ❑ PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />® OVER -BORE DIAMETER of 8 inches to depth of 65 feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />S n Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed 44 Title/Company Regional Manager <br />Print Name Dustin King Date 6.22.22 <br />DEPARTMENT USE ONLY � <br />Application Accepted By: ���, Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/D <br />Facilitv/Site Information <br />FA Name <br />FA PE 2�'.� � WP Reviewed By � � Work Plan Date ��Z,j^� �.D� <br />C 57 ❑ C-57 Authorization for Other to Sign Permit ElWorkers Comp El WorkerComp Waiver ❑Encroachment Permit Access Agreement Lead Agency Approval MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit a0Z2AS $152x 0L 135 (Z� V) P 0 0 LH 4 v <br />500 g•r�� <br />1868 E. Hazelton Avenue � Stockton, California 95205 1 T 209 468-3420 � F 209 464-0138 1 <br />vvww.sjcehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />vvww.sjcehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />