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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/Zip Stockton, CA 95207 Phone (209) 476-8669 Cross Street Rivara Road APN N/A Property Owner* City Of Stockton Phone (209) 937-8381 Address 425 N. El Dorado Street City/State/Zip Stockton, CA 95202 C-57 Contractor Cascade Drilling License# 1058336 Phone g16.638.1169 Address 3000 Duluth Street City/State/zip West Sacramento, CA 95691 Consultant/Sub-ContractorATC 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: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN 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(Air Sparse,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING 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 WELL IDs See comments below ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland 1/1 I C:P_menf❑ 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 feet COMMENTS: Well ID's: MW-6, MW-16, MW-23 MW-241 MW-25 reside in the city's ROW traffic island east of N. Lower Sacramento Rd. and Pacific Ave. MW-9 resides In the city's ROW on thq, northslde sidewalk of Rivara Rd. . See included maps and Table. _ •-, � f�,. r,. thf- �IJ�Z3 - w�at r ,, I hereby certify Joaquin t I a County Ordin complete ance ce Codes and Stais ndards, that the workwill be done in acco dance with q and all other applicable California laws. Signed Title/Company Branch Manager/ATC Group Services LLC Atlas Technical Print Name Jeanne Homsey Date November 10 202 W -' 00 iro. -P RTM NT USE ONLY Application Accepted By: Vu Date Issued: I /Z3 Grout Inspection By/Dates: l Destruction Inspection By/Dates: Facilit /Site Information FA Name r f fh r Ne, FA Address C I C_ I FA# 0 0 1 PR# FA PE WP Reviewed By Work Plan Date ❑ C-57 '*-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver ❑' ryroachment Permit ❑Access Agreement Lead Agency Approval M.FR COMM ENTS/CONDITIONS:t,A � �r� �.� r v1 yl' v rat.) 1 I� .S�x6YI I�(kA,_ _ IrP_ V©(-q�� (_M fr WP TYPE PPE SC FEE INFO AMT REMITTED CHECK# RECV'D BY, D T/E WELL PERMIT# INVOICE#zM Permit Z 0 Z 6 1$152 x ` 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-011 38 1 www.sjcehd.com EHD 29-01 04-04-07 �_ ^�`r��p q�� CV\ � � � act " � �� Site Mitigation Well Permit Application