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S A N J O A Q U I N Environmental Health Department COUNTY c-I u � „" ' Grcatr ess 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 Phone Property Owner* City of Stockton Right-of-Way Address City/State/Zip C-57 Contractor Doulos Environmental, Inc. License# 730042 Phone 916-990-0333 Address PO Box 2559 City/State/Zip Orangevale, CA 95662 Phone 916-761-5224 Consultant/Sub-Contractor Tylor McMillan's Well Service, LLC License# 9201 Address 9530 Hageman Road, Suite B #349 City/State/Zip Bakersfield, CA 93312 CONSTRUCTION WORK TO BE PERFORMED: *Note: offsite Borings/Wells 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(Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ 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 Saarae 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 3 ❑ OVER-BORE DIAMETER of inches to depth of feet ilnk WELL IDs MW 8. MW 9, MW 10 ❑ PRESSURE GROUT To depth of feet below surface JJ) Iasi— �Fr6m_78 to 0 feet below surface:` ki f 0 GROUT SPECIFICATIONS Neat cement ® EXPLOSIVES — TREMIE TYPE TO BE USED El AUGERS ® HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 Teet below 0&de or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San� Joaquin County Ordinance Codes and Standards, and all other applicable California laws.� rr" Title/Company Stratus Environmental, Inc. Signed Print Name Steven Mok Date 09/14/23 DEPARTMENT USE ONLY �7 /� Date Issued: G- Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information ^n �� ' �,/ ` FA Address U ' , SCl 11 FA# 6v Z�9 PR# e, FA Name ) L ��S WP Reviewed By L ) Work Plan Date FA PE � { ❑ C-57 U -57 Authorization for Other to Sign Permit El Worker's Comp El Worker's Comp Waiver ❑ Encroachment Permit El AccessAgreement ea ency Approval FR r COMMENTSICONDITIONS lv U lVl �1, Cd t lr\ (� (tL,7-1_/ �e C ��.�� WP TYPE PE SC FEE INFO v AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit C� $ �#( 2"i D �U �I 1868 E. Hazelton Avenue ockton, California 95205 1 T 209 468-3420 F 209 464- to Mitigation i ation Well Permit Appli r tionn EHD 29-01 04-04-07