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SAN JOAQUIN Environmental Health Department _ ` ..: —COUNTY— 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 7647 Pacific Avenue city/State/ztp Stockton, CA 95207 Phone (209) 476-8669 CrossStreel Rivara Road APN N/A Property Owner* City of Stockton Phone (209) 937-8381 Address 425 N. I Dorado Street City/State/Zip Stockton CA 95202 C-57 Contractor Cascade Drilling License# 1058336 Phone 916 638-1169 Address 3000 Duluth Street Citylstatelzip West Sacramento, CA 95691 ConsultanVSub-Contractor ATC Group Services LLC dba Atlas Technical 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: Offate BodngsNVells 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(VaporfNater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL El PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Oia: Casing Dia: Casing Depth: ❑ INJECTION ftsnarve.ezane) ❑ HANDAUGER GROUT SFAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOILBORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 6 ®OVER-BORE DIAMETER of 8 inches to depth of 40-80 feet WELLIDs See comments below ❑ PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS Portland I/ll Cement El EXPLOSIVES From to feel below surfaceTREMIE TYPE TO BE USED ®AUGERS [IHOSE ElPIPE ElMUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Well IUS: MW-6, M�// 1�, MW-2 MW-24, MW-25hresjdy in the city's ROW traffic ii l nit as Qf N. Lower Sacramento Rd. and Paafic Ave. W-9 resides m t e city s ROW on thg ngrthside st ewa o r�ivara Rd. See included maps and Table. t - tI2 . ' �r M W eY ZO 4Z. -eA Q1( ,Aoo I hereby certify that I am au ho ized to complet his application nd that the wit will be done in acco dance with A lC µ.Lw San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. rA&V NAWL�n pt-e.0 Signed Title/Company Branch Manager/ATC Group Services LLC At asTechnical Print Name Jeanne Homsey Date November 10 202 1, 4-i r1n -ja ra/ DEP RTMEr USE ONLY Application Accepted By: kw, tluc— Dale Issued: I Zo G Grout Inspection By/Dates: I /� Destruction Inspection By/Dales: Q h OrI5 Facilil /Site Information FAName forlo r Irl n i FAAddress C FA# 0() ZLfI PR# 0 ZI FA PE O WP Reviewed By Work Plan Dale 1 ZD Z 0G-57 57Authorizatloa for Oamrto Sign Permit ❑Workers Comp ❑Workers Comp Waiver ment Permit ❑Aaess Agreement ad Agency Approval MFR COMMENTSIC NDITIONS:/AN 0 1A Ih 4 f2. giivX �q l>(�/Q Q.I /�fyr4 ire �'�/<, O [, inACraa c b ntnAAA /,.e vo(CLP e ff i -mi{-r (// 7 ! t — v }e oar . WP TYPE PE SC I FEE INFO IMT REmirrEDf CHECK# RECV'D BY ii D TE WELL PERMIT# I INVOICE# Permit 2q0W� 3 $ ` X 5 1 q90 C 1 ZI Z o'2g°�s6o�6 1868 E. Hazelton Avenue Stockton, Califo ,i/s�x9�x52015 T 20�1sqt'468-3420 F 209 464- 13 www.sjcehd.com EHo29-0700-04-W cm-t, '•\q"�l �� ` \ 52q'© 8333 Site Mitigation Well PerMtAppliration