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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 Inspection: 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 4075 East Main Street City/State/Zip Stockton, CA 95215 Phone 209-464-1431 Cross Street Oro Avenue APN 157-264-11 Property Owner" Mcllrath Family LTD PTP Phone Address PO BOX 326 City/State/Zip Stockton, CA 95201 C-57 Contractor MR Drilling License# 740854 Phone 714-994-0402 Address 13124 Firestone Blvd City/State/Zip Santa Fe Springs, CA 90670 Consultant/Sub-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: Offsite Borings/Wells 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(Airsoame Ozona) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED' ❑AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freelall Depth is 30 FI) WELL]SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:fCHECK ALL THAT APPLY) 4 WELLS TO BE DESTROYED 20 ®OVER-BORE DIAMETER of 2-4 inches to depth of 70-110 feet WELL IDs see attached workplan ❑PRESSURE GROUT To depth of feet below surface I 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 feel COMMENTS: Well IDS, M C, MW2, M 3, 3C-, MW4, MW5, M 8, - — IW1, IW2, IW3, IW4, IW5, IW6, IW7, VEW1, VEW2, VEWj j41 4-o L° It er- Z ZZ I hereby certify that I am authorized to complete this application and that the, rk will be` one in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable -Ca Ifornia laws. Signed � Title/Company PresicW &+H 0616ii 146 MR t ItAq Print Name ,C]f tVP D era Date 11- aD -,m_, DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: ` -y-+f 1\_CL 1 0, 4 iv10- f' Destruction Inspection By/Dates: �) �?v� f>r�"�t ,•Y� c,(c�.l l' S Facilit /Site Information FA Name �� FA Address D:73 n FA# _ PR# (T 311, f, FA PE �f WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver []Encroachment Permit ❑Access Agreement []Lead Agency Approval PAFR COMMENTS/CONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERprMIIT# INVOICE# Permit $152 x V 06�16 j s�°oo g t+65 z 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd EHO 29-01 06-28.21 Site Mitigation Well Permit Application