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SAN)IOAQUIN a '° � �`�'• Environmental Health Department COUNTY Greotness 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 Develo ment Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address �.tp �,N ( � 7t�� W��l5Ty/State/Zip Stockton, CA 95202 Phone Cross street _park Street APN 17 Property Owner' City of Stockton (ROW) Phone Address 345 N. El Dorado St. City/State/Zip Stockton, CA 95202 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone (707) 639-7709 Address 6821 8th Street City/State/Zip Rio Linda, CA 95673 ConsultanVSub-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 Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING 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 Soarge,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 ROYED 5 ®OVER-BORE DIAMETER of 8 inches to depth of 40-65.5 feet WELL IDs MM, MW9 MW10 MW11 MW12 PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat CeMent n 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: �µw� � MW-II 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 �o�,o�� j „�f�, Title/Company Environmental Technican /Atlas Technical _ Print Name Genelle Martin Date 8/4/2025 DEPARTMENT USE ONLY Application Accepted By:�}�'��.._o,l"�- Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name �� 'r D;v�. FA Address t p wL✓ FA# j FA PE Z�6 D WP Reviewed ByZ]Z Work Plan Date At,57 ❑C-57 Authorization for Other to Sign Permit "RrWorker's Camp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement -W Lead Agency Approval I MFR COMMENTS/CONDITIONS: twL') aj4.• �1�ti vlz kv ('t�r�;s�v�- Ir�� tM�.c:- -Am", �'�,ra�+' � x �� A WP TYPE PE Sc C FEE INFO AMTT REMITTED CHECK# RECV'D BY DATE WELL PPE(RR(MIIT#� rn INVOICE# Permit 2 X �CtU)- �` / O� 14— 8((LI ZJWW9IOI/J 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application