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S A N J OA O U I N Environmental Health Department )ur"l- . 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 Joaquln County Development Title,Chapter 94116.3,and the San Joaquin County Well Standards. Job Address East Main Street city/State/Zip Stockton, CA 95215 Phone Cross street Adelbert Ave. APN Property owner San Joaquin County Public Works (San Joaquin County ROW) Phone 209-937-8444 Address 425 N. El Dorado Street aty/stateizip Stockton, CA 95202 C•57 contractor MR Drilling License# 740854 Phone 714-994-0402 Address 13124 Firestone Blvd City/State/Zip Santa Fe Springs, CA 90670 ConsultanuSub-Contractor Atlas Technical License# Phone 209-579-2221 Address 1117 Lone Palm Ave., Ste. 201 B —City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:*Note: OHsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PPE ❑ EXTRACTION(Vapor/Waler) ❑ HAMMERIORMEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTILEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boeing Die: Casing Die: Casing Depth: ❑ INJECTION(Ak6m e.ozmel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Ma lmum Freelal Depth is 30 Ft) WELUSOIL BORING Its GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLn 416 #WELLS TO BE DESTROYED 12 ®OVER-BORE DIAMETER of 2 inches to depth of 75-111 feel WELLIDs see attached WOr an �E330R Todepthof 111 feet below surface 601�k l�) GROUT SPECIFICATIONS ea cement ❑.EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ®AUGERS [:]HOSE ❑PIPE Ck MUSHROOM CAP ®3 feet below surface or feel below surface' >3 fee �ZOZ COMMENTS: Well Id's MW6A, MW6B, MW6C, MW7A, MW7B, MW7C, MW10A, MW10B, MW10C, MW 11C, Y MW14B, MW14C. /k1( -IC' bZ deSy� b bl�fi; firer Z� �� I hereby certify that 1 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 alpp�liica to Cailfomla laws. 6"f0I el'I deyp Signed Ma Title/Company rtCbltlPlll�7a{� AbA me Print Name ALP, 1"ill e rn Date I r2 - a D • a �a I ,, `1—J DEPARTMENT USE ONLY Application Accepted By: VV dll pp Date Issued: 5, Grout Inspection By/Dates: a l(/ 2U 2 b r � /7,�w S ,l Destruction Inspection By/Dates: �`r2H23 "'� i 6!"' Facilit /Site Information .f FA Name ' FA Address FA# D FA PE Zg6`O WP Reviewed By J Vj Work Plan Date G57 ❑C57 Aullwization for Otherto Sign Permit ❑Warkefscomp ❑Wakets Comp Waiver ❑Enaoadunent Permit ❑Access Agreement P20gencyApipnwal FR �ZZ COM ENTSICONDITIONS: jWPTYPEj PE SC FEE INFO JAMTREMITTED1 CHECK# REcv,n wv D TE WELL PERMIT# INVOICE# Persil �OZ �I $1,12x Z w 2:l W Z,$6 + loos xf 1A v-A if ' 134348'F(5 5&09If,,&5s2 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 1 www.sjgov.org/ehd EH0 29-01 OB-28.21 Site Mitigation Well Permit Application