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SAN JOAQUIN Environmental Health Department c_ G I_1 N T 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 151 E. Alder St. City/State/Zip Stockton, CA 95204 Phone Cross Street N. El Dorado St 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,4PECIFIEATIONS ® MONITORING 1 ® HOLLOW STEM BORING DEPTH 120 ft ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor;Water) ❑ HAMMER-DRIVEN 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 91 PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ® No Boring Dia: Casing Dia: Casing Depth. ❑ INJECTION(Ar Soamo.Ozonol ❑ HAND AUGER GROUT SEAL DEPTH 101' TREMIE TYPE TO BE USED; ®AUGERS ❑HOSE ❑ PIPE ❑ OTHER ❑ OTHER _ GROUT SEAL PUMPED? ®Yes ❑No (Note.Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs MW-29 GROUT SPECIFICATIONS neat cement 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 GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [-]AUGERS [-] HOSE ❑ PIPE ❑ MUSHROOM CAP E]3 feet below surface or feet below surf ce if>3 feet COMMENTS: �- . ,, lJl1r,� i �� I hereby certify that I am authorized to complete this application and that the work will be done In accordance with 3 'it •�' San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed It4-11— Title/Company Prd��t es t-AR 1 Print Name Mo , r Date d aa. 2 3 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: A&21yZ Destruction Inspection By/Dates: Facili /Site Information it FA Name 'ji/1 0 c D FA Address G rq FA# (� PR# FA PE Zk> WP Reviewed By Work Plan Date � m waiver -Enereahment Perm ❑Access Agreement 4d Agency Approval ❑ M R-_ G57 ❑C•5� Authorization for Other to Sign Permit ❑Vvorker's Comp ❑Worker's Comp Ya �-(�, J Q 1` 1 COM ENTS/CONDITIONS: }- t 5 rf�clP�,St y O c Q C Q �Gl r et ` ��5 Q WP TYPE PE SC FEE NFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit �� $152 x , .. - 5 7-S t 7-5 S Cso S J 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.coni EHD 29.01 04-04-07 Site Mitigation Well Permit Application