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SAN JOAQUIN <br />Environmental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All 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 3076 TurnDike Road <br />City/State/Zip Stockton, California 95206 Phone <br />Cross Street Walker Slough / Downing Street APN 165-280-054 <br />Property Owner* Komalpreet Atwal Phone (209) 390-8382 <br />Address 3701 S. Linne Road City/State/Zip Tracy, CA 95304 <br />C-57 Contractor TEG - Northern California Inc. License# 706568 Phone (916) 853-8010 <br />Address 113501 Monier Park Place City/State/zip Rancho Cordova. CA 95742 <br />Consultant/Sub-Contractor ATC Group Services LLC License# Phone (209) 579-2221 <br />Address 1117 Lone Palm Avenue, Suite 201 City/State/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />NUMBER <br />INSTALLATION TYPE <br />❑ MONITORING <br />❑ <br />HOLLOW STEM <br />❑ EXTRACTION (Vapor/Water) <br />❑ <br />HAMMER/DRIVEN <br />N SOIL VAPOR PROBE <br />Four ❑ <br />MUD ROTARY <br />X SOIL BORING <br />Three <br />PUSH POINT (GP/ CPT) <br />❑ INJECTION (Air Sparge, Ozone) <br />❑ <br />HAND AUGER <br />❑ OTHER <br />❑ <br />OTHER: <br />WELL/ SOIL BORING IDs <br />RECV'D BY <br />DATE <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />BORING DEPTH to first amd vvtr ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />DIA. OF BOREHOLE 1 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS None TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED [-]AUGERS ❑HOSE [-]PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed i. E, <.<: ,+'; ,,.- Title/Company P.E. Branch Manager ATC Group Svs LLC <br />Print Name ieanne momsey Date June 30, 2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />FA Name <br />FA Address <br />FA# <br />PR# <br />FA PE <br />WP Reviewed By <br />Work Plan Date <br />❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />PESC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />$152 x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 I www,sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />