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SAN JOAQUIN Environmental Health Department <br /> N J.".. COUNTY <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APN: 155-12-014 24 Hours Advance Notice Required For All Inspections <br /> PARKING LOT <br /> CALL (209) 953-7697 For INSPECTIONS <br /> tApplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is'made in compliance with San JoaquirlCounty Development Ti e, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 1250 South Wilson Way :! �, City/State/Zip Stockton, CA 95205 Phone <br /> Cross Street `'E. Charter Way (E. Dr. M.L.K. Boulevard) APN 155-12-014 <br /> Property Owner* Fairgrounds Industrial Park Phone 209-462-8538 <br /> Address 749 29th Avenue City/State/Zip San Francisco, CA 94121 <br /> C-57 Contractor Cascade Drilling License# 1069034 Phone (925) 849-6970 <br /> Address 120 S. 23rd Street City/State/Zip Richmond, CA 94804 <br /> Consultant/Sub-Contractor CDIM Engineering, Inc. License# 1020239 A HAZ Phone 415-498-0535 <br /> Address 45 Polk Street, 3rd Floor City/State/Zip San Francisco, CA 94102 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 feet ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 inches ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER <br /> El SOIL BORING 1 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE <br /> ❑ OTHER ❑ THE Direct Push GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs MMF-SS-07 GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs p ' _ ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> hereby certify <br /> ththat I am authorized to complete this application and that the work will be done in accordance with <br /> S_4 � aqu ty Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed (/� Title/Company BU Manager/Cascade <br /> Print NameChristopher Tatum Date10/20/2022 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: I �� <br /> Grout Inspection By/Dates: �. <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address / S�� ,�� FA# 7 114 PR# V S <br /> FA PE WP Reviewed By ��� Work Plan Date G+ 10/ 3!f'ZZ <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑ Encroachment Permit ❑Access Agreement ead Agency Approval FR <br /> COMMENTS/CONDITIONS: < � � �` � _ � - l✓ ��1 � ,�� _ v����` �', <br /> WP TYPE PPE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE` f jWELL PERMIT# INVOICE# <br /> Permit !� $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 9 05 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />