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S A N J O A Q U I N 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 102 S Wilson Way City/State/Zip Stockton, CA 95205 Phone Cross Street Market Street APN 15502065 Property Owner* Knowles Family Irrevocable Trust Carl Knowles -Trustee Phone Address PO Box 640 City/State/Zip Woodbridge, CA 95258 C-57 Contractor Doulos Environmental, Inc. License# 730042 Phone 916-990-0333 Address PO Box 2559 City/State/Zip Orangevale, CA 95662 Consultant/Sub-Contractor Tylor McMillan's Well Service, LLC License# 9201 Phone 916-761-5224 Address 9530 Hageman Road, Suite B #349 City/State/Zip Bakersfield, CA 93312 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ElMONITORING ElHOLLOW STEM BORING DEPTH [IBOLTED TRAFFIC BOX [I STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ElPUSH POINT(GPI CPT) CONDUCTOR CASING [IYes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air sparoe 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 S Y 1, � DESTRUCTION WORK TO BE PERFORMED: \ DESTRUCTION METHOD: (CHECK ALL THAT APPLY) N Q `Qb`� #WELLS TO BE DESTROYED 31 ` iy 11�"-A?- ./ ❑ OVER-BORE DIAMETER of inches to depth o' feet \ WELL IDs see comment box below o ❑ PRESSURE GROUT To depth of Jeeee below surface (eke GROUT SPECIFICATIONS Neat cement ® EXPLOSIVES From 120 to �3+C feet below surface l TREMIE TYPE TO BE USED ❑ AUGERS ® HOSE ❑ PIPEVMW-,5,,',k4W-6, ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: Well IDs: MW-1, MW-2 MW-3 MW MW-7 W-8 MW-9 MW-10 MW-13B, MW-14, MW-16A, MW-16B, MW-17C SVW 1, VW-2, VW 3, VW,4, VW 5. IW-1A/B, �VjJ-2A/pt,{� 4A/B..IW-5(j/R nniellc Iw-1q/B throug�W-5AlBtlare nested wets 2�I ca"sin�os� in each borehole) i 1 1( 11C r�te4k I. �� d r �riy w �� i�l CCU$ /`�l�v'' GLq ��, 1�1Cid� '� i 11 � S I hereby certify that f am autdori: to th,o apF11UULavn a,,,. ., a. .Se work will be dons m accor ance nn, San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. .f ; Cbr� Signed r5&".Ili 70 � Title/Company Stratus Environmental, Inc. `��rll I Print Name Steven Mok Dateoa(28/23 Pe rm _ ; J i DEPARTMENT USE ONLY It/Avl_ �f °� Application Accepted By: Date Issued: C 4 3 Grout Inspection By/Dates: Destruction Inspection By/Dates: t 3 1 Facilit /Site lnform4on FA Name ow e s . t Soyl FA Address �� FA# QD Z•� S � PR# D 5 �{ FA PE Zt� WP Reviewed By Work Plan Date z. Lo Z ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver Encroachment Permit ❑Aocess Agre9ment ad Agency Approval MFR COMM S/CONDITIONS:/,- . rm�� S (Q IJ�r1 n/1 1y 1U W - g ;A< s(� ;-� W h: ►M v `J bleS ei i IFS .i it WP TYPE 1JPE' SC FEE INFO AMT REMITTED1 CHEECK# RECV'D BY DATE WELL PERMI INV I Permit 2 q/Z 3� 3$�b�� 5� �I(.I l.G Jj l� o I ("n Al aqa(rae peril':-I tTrQ d+ -0138 i www �mceIhd.q" 186`8 E. Hazelton Avenue I Stockton, California 95205 209 468-3420 1 F 209 464 . 29-0`Op-007� Site Mitigation Well Permit Appllcaj