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S A N J O A Q U I N Environmental Health Department COUNT Y 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 1514 East Market Street City/State/Zip Stockton, CA 95205 Phone Cross Street South Eugenia Street APN 15502054 Property Owner* Tasnim Akhtar Phone Address 1514 East Market St City/State/Zip Stockton CA 95205 C-57 Contractor Doulos Environmental, Inc. License# 730042 y '�n t� / ' 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 Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING El HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX El STOVE PIPE ❑ EXTRACTION(VaporMlater) ElHAMMER/DRIVEN DIA.OF BOREHOLE ❑ MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER El SOILBORING El PUSH POINT(GP/CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Saarge 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) 41 WELD SOIL BORING IDs GROUT SPECIFICATIONS C �, mobil DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THATAPPLY) �" #WELLS TO BE DESTROYED 5 ❑ OVER-BORE DIAMETER of.inches to depth of f et WELL IDs MWA 1, MW-12, MW-15A, MW-15B, MW-15C ❑ PRESSURE GROUT To depth of feet below surface 1 c�C GROUT SPECIFICATIONS Neat cement ® EXPLOSIVES From'S to 120 feet below surface �b TREMIE TYPE TO BE USED El AUGERS ® HOSE ❑ PIPE El MUSHROOM CAP ❑ 3 f t below surface or feet below surface if>3 feet COMMENTS: // ()lJic � Ct (�/� r-� �'�//]�)�� 't �I[� "i�� JCJ 1 ,�^i >e. I hereby certify that I am authorized to complete this application an that the work will be done in accordance with n Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Stratus Environmental, Inc. Signed Title/Company Print Name Steven Mok Date 08/28/23 DEPARTMENT USE ONLY `70 'e,5 Application Accepted By: Date Issued: L Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name ��.yti' t i FA Address f L FA# ©� PR# ©,� FA PE Z �� WP Reviewed By '� t ' Work Plan Date CU ?,3 ElC-57 ElC-57 Authorization for Other to Sign Permit ❑ Worker's Comp El Worker's Comp Waiver ig.Encroachment Permit ElAccess Agreement ead Agency Approval R COMMENTS/CONDITIONS: `� y y� k �D irJLf-� ItU�l r5 .s , vu �4ecfr�`Y'l t r�/l�k A-y �f'1Cr-I C' \ Q�� 5 �% II Q � �� fo 10 � WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 740n z:� vJ Pei 2 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com Site Mitigation Well Permit Application EHD 29-01 04-04-07