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a artment �`,,, Environmental Health De t r `Z SANiJOAQUIN —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 619 N. Hunter St City/State/Zip Stockton, CA 95202 Phone Cross Street Oak Street APN 139-060-150 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 BoringsANells 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) ❑ HAMMERIDRIVEN 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 Sgarge.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) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BED STROY D 7 1 ®OVER-BORE DIAMETER of 8 inches to depth of40-65.5feet WELL IDs MM, M46, M 3 2 4 ❑PRESSURE GROUT To depth of feet below surface GROUT SP CIFICA ONS Neat ement ❑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: 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 a�� 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: R �w� Destruction Inspection By/Dates: V 1 S< .S-2 �I y Z,S V Sr Y v 3� I IZ Facilit /Site Information % kI W X St. FA Name o\_R ,,,•,c, L I FA Address L�,lw -J V' FA# o V ct PR# v i.fi c� FA PE ct 6 p WP Reviewed By Work Plan Date t Z 'W2-57 EE-57 Authorization for Other to Sign Permit`Wworker's Comp ❑Worker's Comp aiver ❑Encroachment Permit ❑Access Agreement j[�, Lead Agency Approval )Q•MFR COMMENTS/CONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2°I J 1 t 7 $1,5�x 5'� a S ) t l ( 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd EHD 2Mi 06-28-21 Site Mitigation Well Permit Application