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SAN �JOAQUIN Environmental Health Department, �at —COUNTY— _ ,^ Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APN: 166-12-0151 24 Hours Advance Notice Required For All Inspections SLOUGH I 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 appli�ati Is ads in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 1 0 South Wilson Wayti r LZ Citylslate/zip Stockton, CA 95205 Phone Cross Stree E. Charter Way (E. Dr. M.L.K. Boulevard) APN 155-12-015 Property owner Fairgrounds Industrial Park Phone 209-462-8538 Address 749 29th Avenue city/State/zip San Francisco, CA 94121 c-57 Contractor Cascade Drilling License# 1069034 Phone (926) 849-6970 Address 120 S. 23rd Street cityfstatefzip Richmond, CA 94804 Consultant/Sub-contractor CDIM Engineering, Inc. License# 1020239 A HAZ Phone 415-498-0535 Address 45 Polk Street, 3rd Floor city/stalelzip San Francisco, CA 94102 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 feet ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapwMale4 0 HAMMERIDRIVEN DIA.OF BOREHOLE 2.25 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOILBORING 4 ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ONO Boring Dia: Casing Dla: Casing Depth: ❑ IWECTION(A Some,Ozonal ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ THE Direct Push GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Fit WELUSOILBORINGIDS MMF-SS-OB. MMF-SS-09. MMF- GROUT SPECIFICATIONS SS-10, MMF-SS-11 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of—inches to depth of feet WELL IDs _ 1 / / _ ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feelbelowsuriace TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface it>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done In accordance with Sea"uin County Ordinance Codes and Standards,and all other applicable California laws. Signed <il--- /G Title/Company BU Manager/Cascade Print NameChristopher Tatum Date10/20/2022 DEPARTMENT USE ONLY 9I J/ 2 Application Accepted By: Date Issued: /D J f 2 Grout Inspection By/Dates: �� Destruction Inspection By/Dates: ' Facilit /Site Information CI" C) Z FA Name I Mk r+fl FA Address 125'O IV ti SM 1FA# Q D PR# 0 0 FA PE .y 1 1WP Reviewed By V V 1 Work Plan Dale 9 IZoo?—a 7 ❑C-RAuthorizawn forothe(to Sign Permit ❑Wmkees Comp ❑Workefs Camp Waller 011nomachment Permit ❑Aaess Agmemenl Agerwy Appoval 1 / COMMENTSICONDITIONS: Lqy or rCS IIS Lo -:HP ffr- We-(I ST �S I z WP TYPE I PE I SC FEfi INFO AMT REMITTED1 CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit I Zqob1315 $ X 3( L I CC4 T Ul P00 Q qq Gams l ,S L, 89s q98 gAo095. 1L9 1868 E. Hazelton Avenue I Stockton, California 9 205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHO29-01 N9 -07 Site Mitigation Well Peril Application