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SAN JOAQUIN Department Environmental Health De <br /> Q —COUNTY <br /> rri <br /> `c"�4ronC: Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 800 West Church Street Ctt/ l Ofa city/State/zip Stockton, CA, 95203 Phone NA <br /> Cross Street S. San Jose Street APN 14523012 <br /> Property Owner* Newark Group, Inc Phone (614) 226A530 <br /> Address 3200 Highlands Parkway, Suite 300 citylstatelzip Smyrna, GA 30082 <br /> C-57 contractor Cascade Drilling License# 1058336 Phone (510) 478-0858 <br /> Address 3459 Collins Ave City/statelzip Richmond, CA 94806 <br /> Consultant/Sub-Contractor AECOM License# NA Phone (916) 207-3053 <br /> Address 2020 L St, Suite 300 City/Statelzip Sacramento, CA 95811 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: 08site BoringsANells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTAEtAT(ON TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaporM'ater) ❑ HAMMERIDRIVEN OIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION f Soaoe.o:aml ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: 17t DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED '3 (e(µI z oy'y OVER-BORE DIAMETER of $ inches to depth of 24-67 feet b Y (•-i S A <br /> WELLIDs DMW-1, DMW-4, DMW-5A, ❑PRESSURE GROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS Portland Cement-Type I/Neat Cement [I EXPLOSIVES From to feetbelowsurface <br /> TREMIE TYPE TO BE USED [I AUGERS ❑HOSE PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: See Table 1 of Work Plan for total depths of wells to be destroyed. <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed P K(MA Title/Company Regional Manager/Cascade Drilling <br /> Print Name Dustin King Date 8/1612023 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: ' v Date I sued: 10 / 7—/ 2� 43 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilil /Site Information <br /> FAName 6G3 ejp FAAddmss I goo W , Ckvrtk I FAN DQ 3 PRY624, <br /> FA PE a 60 WP Reviewed By I J V1 I Work Plan Date 1 V / 'ZO <br /> C-57 ❑C-57AuthorizationforOtherto Sign Permit ❑Wolkefs Comp ❑Workels Comp Waiver ❑Encroachment Permit ❑AccessAgmement Agency Approval FR <br /> COM 96 <br /> TS/CONDITIONS: <br /> WP TYPE I PE SC I FEE INFO AMT REMITTED CHECK# I RECV'D EIY DATE WELL PERMIT# INVOICE# <br /> Permit 02 (3 141 x 3 �F 23 44 <br /> 1868 E. Hazelton Avenue I Stock•1W^' n,�alifornia 95205 T 209 468-3420 �-Q <br /> F 209 464-0138�wwww.sjcehd ccom <br /> EHD 29,0104-20-23 (y� / C, L+ Site Mitigation Well Permit Appliwtim <br />