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n S A N J OA Q U I N 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 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 610 N. Hunter St City/State/Zip Stockton CA 95202 Phone Cross Street Oak Street APN 139-060-330 Property Owner" Service First of Northern California Phone (209) 644-6300 Address 102 W Bianchi Rd. City/state/zip Stockton, CA 95207-7132 C-57Contractor Confluence Technical Services, Inc. License# 1035255 Phone (707) 639-7709 Address 6821 8th Street City/State/Zip Rio Linda, CA 95673 Consultant/Sub-Contractor_Atlas Technical Consultants, LLC License# 1083331 Phone (209) 579-2221 Address 1117 Lone Palm Ave., Ste. 201 B City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsA/Vells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE STRO D _ ry OVER-BORE DIAMETER of 8 inches to depth of 40-45feet WELL IDs MW2, M 4. M65,A, 1, 2 ;.PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat Cement ,_�❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ❑3 feet below surface or feet 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 ��ne e %�/�u� Title/company Environmental Technician / Atlas Technical Print Name Genelle Martin Date 8/4/2025 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: �i� Destruction Inspection By/Dates: I - l Z sr1 kW Z '[5 79 Mw t 01IS X f Yw 2 R Facili /Site Information Perm r Iit ( q I �6 ' FA Name "rN a FA Address I 6t D 'o 4 a w�� FA# �(,J 3 �`1 � PR# FA PE 1 '2'L WP Reviewed By Work Plan Date 9 IL t 5� C-57 6,b1,57 Authorization for Other to Sign Permit orkers Comp ❑Workers mp aiver ❑Encroachment Permit ElAccess Agreement Lead Agency Approval MFR COMMENTS/CONDITIONS: Ia�tN � ��( �i,r`5 W S�� V�►✓ j r�G ( �- WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PP�E,,RppMIT# INVOICE# Permit 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application