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S A N J O A Q U I N Environmental Health Department 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 1121 Annabelle Lane City/State/Zip Stockton, CA 95215 Phone Cross Street Main Street APN 172-200-120 Property owner Golden Opportunity No. 28 LP, Golden Management Inc. Phone Address 4900 Santa Anita Avenue, Suite 2C City/State/Zlp El Monte, CA 91731 C-57 Contractor MR Drilling License# 740854 Phone 714-994-0402 Address 13124 Firestone Blvd city/staterzip Santa Fe Springs, CA 90670 Consultant/Sub-Contractor Atlas Technical License# Phone 209-579-2221 Address 1117 Lone Palm Ave., Ste. 201 B Citylstatelzip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELUBORNG NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaportiVater) ❑ IUMMERIDRIVEN CIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTILEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASNGTHICKNES5 TYPE OF CARING: ❑STEEL ❑PVC[IOTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASNG ❑Yes ❑No Boring Dia: Casing Die: Cutting Depth; ❑ INJECTION f/}speencozonel ❑ HANDAUGER GROUT SEAL DEPTH TREME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nate:Maximum Free(as Depth is 30 Ft) WELLISOIL BORING Ds GROUT SPECIFICATIONS _I DESTRUCTION WORK TO BE PERFORMED: D TR TION METHOD: CHECK ALL THAT APPL All �o LW r 'lpe" #WELLS TO BE DESTROYED OVERBORE DIAMETER of—inches to depth of teal 1—`l WELLIDs MW9A M e� To depth of75-110 feet below surface doe+ GROUT SPECIFICATIONS ea cementEXPLOSIVES From lo_feelbebw sudace Z TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE (OPIPE ®MUSHROOM CAP (a3 feel below sudace or feel below, if>3 feet COMMENTS: fFjt `f0 lac („�Vy r, b �QS L� L � � O�rz.1'Zf�� Y�Z2 7 �2,n 7cLt,fw I hereby certify that I am authorized to complete thisrapplication and that the work will be done In accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable alifornfa laws. II Signed �T - Title/Compan^y Pmj A�+f �fr'�r/LA dba M I)Pr�/itlR Print Name S�c�Q" Q 6c�lIV Dale I -- .D - as aalj EPARTMENT USE ONLY /6 Z OZZ Application Accepted By: Date Issued: Grout Inspection By/Dates: 1• Destruction Inspecti 'Dates: Z Facillt ISile Information } 1" FA Name r f FA Address �. Ma�, FAR p0 ZtF PRlJ FA PE 9 v WP Reviewed By —.f LA/ Work Plan Dale 2 2p2 G57 ❑C57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Walver ❑EnrzozdumentPmnli ❑Access Agreement Lead Agency Approval �MFR COM ENTS/CONDITIONS: WP TYPE I PE SC I FEE INFO JAMT REMITTED CHECK#I RECV'D Y D TE WELL P RMIr# INVOICE# Permit I`L 0 Z 1 3 i $152 x �� 7f W r o d 1868 E. Hazelton Avenue I Stockton, California 95205 i T 209 468-3420 i F 209 464-0138 www.sjgov.org/ehd EHD 29-01 06-28.21 Site Mitigation Well Pernrl Appeeation