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° OL)'"` SANoJOAQUIN Environmental Health Department n artment —COUNT Y C- c, t�? / 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 600 N Holt Road city/Slate/Zip Stockton, CA 95206 Phone None Cross Street W House Road APN 13l-210-20 Property Owner' 140 Orchard/Brent and Janet Holtman Phone 209-404-0596 Address 12191 East Louise Avenue City/State/Zip Manteca, CA 95336 C-57 Contractor Cascade Drilling, LLC License# 1058336 Phone 518-225-1429 Address 3459 Collins Ave City/StatelZip Richmond,CA 94806 Consultant/Sub-Contractor Tanya Schermer, Professional Geologist License# PG#10096 Phone 209-770-0731 Address 21278 Phoenix Lake Road City/Slate/Zip Sonora, CA 95370 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BodngsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH -20fl ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ DURACTION(Vapor/Water) ❑ HAMMER7DRIVEN DIA.OFBOREHOLE 2to4indms ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL [I PVC ❑ OTHER ® SOILBORING 1 ® PUSH POINT(GP/CPT) CONDIICTORCASING ❑Yes ❑No Boring Dia: Casing Via: Casing Depth: ❑ INJECTION p&swme.ozmal 0 HANDAUGER GROUT SEAL DEPTH THEME TYPETO BE USED: [I AUGERS [I HOSE [I PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mauro F fall Depth is 3D Ft) WELL/SOIL BORING IDS GROUT SPECIFICATIONS '�. U /.O//N O.nn 1/ ,6� In will also be to groundwater for amalt sample. Z-2A DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: GHECKALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL Ds ❑PRESSUREGROUT To depth of_feel below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED []AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin CCou/nnty Ordinance Codes and Standards,and all other applicable California laws. Signed /B/Lc/CL 3G�l r Title/Company Senior Project Geologist/Petralogix Engineering an MPE Company Print Name Tanya Schaffner Date 6-8-2023 DEPARTMENT USE ONLY Pr�� Application Accepted By: Date Issue ; Grout Inspection By/Dales: Destruction Inspection By/Dates: Facillt /Site Information h FA Name S' FA Address OO FA# �� / . PR# J (� FA PE 76 WP Reviewed By Work Plan Date j Z Ad,{p„ d„� ❑C-57 57Authorizauon for Other to Sign Permit ❑Worker'ss Cyyylllo,,,m'''p ❑Workers Comp Waver ❑Encroachment Permit ❑Access Agreemlent ❑1L/ead/Agency Approval ' FR y eMA;( COMMENTS, OND CONDITIONS: 'a— ref ff�u Z�-� �C� WQ�( K 7/ 1 6/ Ole3 avl�lafrc�s (z' . --,Z- • 2 WP TYPE PE SC FEE INFO JAMT RENgTTEDj CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# Permit �lsl$156x 65 Ce 3 WP00441+7 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2D-0104-20-23 /6 3 s6 Gzs Site Mitigation Well PerrNt Appllcalim