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SAN JOAQUIN Environmental Health Department COUNTY 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 ROW near 1536 N. Hunter St. City/State/Zip Stockton, CA 95204 Phone Cross Street E. Harding Way APN Property Owner` City of Stockton Public Works Phone 209-937-8381 Address 425 N. El Dorado St. City/State/Zip Stockton, CA 95202 C-57 Contractor M R Drilling License# 740854 Phone 714-994-0402 Address 13124 Firestone Blvd. City/State/Zip Santa Fe Springs, CA 90670 Consultant/Sub-Contractor ATC Group Services LLC dba Atlas Technical License# Phone 209-579-2221 Address 1117 Lone Palm Ave. Ste. 201 B City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (Z MONITORING 2 El HOLLOW STEM BORING DEPTH 80-120 ft ®BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(VaporlW'ater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8 in ❑ MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Sch. 40 TYPE OF CASING: ❑STEEL KI PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes 91 No Boring Dia Casing Dia: Casing Depth: ❑ INJECTION(Air Spame,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 61-101' TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ® Yes ❑No (Note.Maximum Freefall Cepth is 30 Ft) WELU SOIL BORING IDs MW-27, MW-28 GROUT SPECIFICATIONS neat cement �Y DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface tA • v GROUT SPECIFICATIONS ❑ 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 fe t -- COMMENTS: ZF �s ��- �, ��ci►i .. C12O� a m, p d F C Lt P, 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. Signed ,. jy - Title/Company PteSidem+ i/ D6 I U' „4 I./DZ� Print Name S �-C J� I�+lo )C r A Date 02- g a- a 3 21 t,1� 1� DEPARTMENT USE ONLY E�`(.� - Application Accepted By: Date Issued: Grout Inspection By/Dates: 4"YA4; 2 / Destruction Inspection By/Dates: ✓� Facilit /Site Information FA Name goc� i5v ® —TFA Address ` �r FA# PR# FA PE -2- C9 WP Reviewed By Wa. ork Planate D 2�22, �, �� E]C-57 ElC-57 Authorization for Other to Sign Permit El Worker's Comp ❑Worker's Comp Waiver ncroachrnent Permit 'E7 Access Agreement ,ead Agency Approval ElMFR AO� COMMENTS/CONDITIONS �� S �r-r, YQS � SY�� •�. �� .( � {� ��• �� -d fit^ Lkl� �p WP TYPE PE Sc FEE INFO JAMT REMITTED1 CHECK# I REC�V D BY DATE WELL PERMIT# INVOICE# � L Permit $152 x I < '�.J 2f G W V00 4 �J 1868 E. Hazelton Avenue Stockton, California 95205 ( T 209 468-3420 1 F 209 464-0138 1 www.slceh`�.co S EHD 29-01 04-04-07 Site Mitigation Wet(Permit Application