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SAN 10AQUIN Environmental Health Department —COUNTY— Greatness grows here. 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 andlor install the work described. Ojob This applicat`ior�n is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Add/� QQ Stockton, CA 95267 res§ 'mast Fremont Street City/State/Zip Phone 209 466 5050 Cross street Laurel Street APN 141 112 230 Propertyowner* William and Rime Saleh Phone 20 A66-5050-----� Address P.O. Box 7337 City/state/zip Stockton, CA 95267 C57 Contractor TEG License# 706568 Phone (y L Address 11350 Monier Park Place cityistate/zip Rancho Cordova, CA 9 42 Consultant/Sub-Contractor Atlas Technical License# Phone 1 Address 1117 Lone Palm Avenue, Suit 201 B CitylState/zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offate Borings/Wells Require Access Agreements or Encroachment Permits TYPEOFWELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 11 ft. ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporM'aler) ❑ HAMMERORIVEN DIA OF BOREHOLE 2 in. ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ® SOILVAPORPROBE —❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER IM SOILBORING 2 ® PUSH POINT(GPI CPT) CONDUCTORCASING [I Yes ®No Bomg Dia: Casing Oia: Casing Depth: ❑ INJECTION(Ak Swoe.Oimel ❑ HANDAUGER GROUTSEALDEPTH 11 ft. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 FQ WEWSOILBORING IDS GROUT SPECIFICATIONS Neat cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDS ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED [I AUGERS ❑HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet COMMENTS: - I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed <.—f,4Z:2� Title/Company Senior Geologist/Atlas Technical Pant Name Todd Hefner Date 5/16/23 EP ENT USE ONLY // D Application Accepted By: Date Issued: !�!L Grout Inspection I Dates: Destruction Inspection By/Dates: Facilit /Site Information t �f FA Name V4-0 SqFA Address W8 - FA# Ov -L PR# I 6.!;-q bLtV ��.Vllr FAPE _r?-9 4 0 1 WP Reviewed By I Work Plan Date Z Z1 Z0Z2" I ❑C57 C57Athorhallon for other mSign Permit ❑Workers Camp ❑Worke7s Comp Waiver ❑Enceeadmienti' mit ❑Access Agmeme LeadAgemyApproval MFR N Q� COMMENTS/C nONS: Ste_ pQ SC C r ak t IJVI*1 29 o z3 2 ��sL;YtAra OJe�tsllSrlq st �-t�. two VA-Vbr' Qrabe.s. WP TYPE PE SC I FEE INFO JAMT REMITTEDJ C-HHECpK# RECV-D BY DATE WELL PERMIT#2 INVOICE# Permit O � $156 x 0G�Z I I `12 b d'1- d T � OcT 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 1 WWW.sjceh .Com g EHD2&Ot 04-20-23 �. g� � ',�/ e / 10 �//f't