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"uu S A N J O A Q U I N Environmental Health Department �`y c —COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 15400 Steinegul Road City/State/Zip Escalon, CA 95320 Phone (209) 607-0414 Cross Street Lone Tree Road APN 229-12-022 Property Owner* Steve Sawyer Phone (209) 996-8065 Address 15400 Steinegul Road City/State/Zip Escalon, CA 95320 C-57 Contractor Cascade Drilling License# 1058336 Phone (510) 478-0858 Address 120 South 23rd Street City/State/Zip Richmond, CA 94804 Consultant/Sub-Contractor ATC Group Services LLC License# 1021509 Phone (209) 579-2221 Address 1117 Lone Palm Avenue, Suite 21OB City/state/zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING 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 ❑ SOIL VAPOR PROBE ❑ 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 Soarae.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 2 'OVER-BORE DIAMETER of 2 inches to depth of 112 feet WELL IDS M W 12, M W 13 ROUT To depth of 112 feet below surface GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMErTS: ee ATC oni oring ell Destructi n orkplan dated F bru 12, 202 VM s PO e- r�Xy per s ( I hereby certify that I m author' d to complete this aalicalrion and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Consultant / ATC Group Services LLC Print Name Todd Hafner Date 5/8/20 drnVyXI RTMENT USE ONLY Application Accepted By: Date Issued: 6/0_0 /z0 Grout Inspection By/Dates: Destruction Inspection By/Dates: $�Q -� Facilit /Site Information - / FA Name O/ ,�' FA Address r� 3 (�/�l FA# O Z� l PR# QS FA PE �t�9 1 WP Reviewed By ✓✓11 vv i A ) Work Plan Date ❑C-57 57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/C NDITIONS: R f-' �� LU C I Z� ��- -A WP TYPE PE sC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit b Z 303 $152 x 'Z/ 3 I 6 I W d0 4-0 0 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 4644 3 t?Cehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application