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SAN JOAQUIN a Environmental Health Department COUNTY '�'9clroa@% 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 800 West Church Street city/state/zip Stockton, CA, 95203 Phone NA Cross street S. San Jose Street APN 14523013 Properly Owner* Axis Group Inc Phone (614) 226-4530 Address 1466 Balfour Drive City/State/zip Lathrop, CA 95330 c-67 contractor Cascade Drilling License# 1058336 Phone (510) 478-0858 Address 3459 Collins Ave city/statelzip Richmond, CA 94806 Consultant/Sub-Contractor AECOM License# NA Phone (916) 207-3053 Address 2020 L St, Suite 300 city/Statelzip Sacramento, CA 95811 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsM/elis Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vaporil ler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes [I No Boring Dix: Casing Dia: Casing Depth: ❑ INJECTION(Ptsexae.Ozone) ❑ 14ANDAUGER GROUTSEALDEPTH TREMIETYPE TO BE USED: ❑AUGERS [I HOSE [I PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs GROUT SPECIFICATIONS iF-41 cD�Dpn vas �t�qxwLcSS L:M Per DESTRUCTION O��_RKTO BE PERF(SRM : S'(V# G��1119 l DESTRUCTION METHOD: CHECK ALL THAT APPLY) #WELLS TO BE DE, -QQ... tlER-BORE DIAMETER of 8-14 inches to depth of 40-80 feel b y (-f s A WELL IDs DMW-� DMW-5B ti ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFIGATIO0 Portland Cement-Type I/Neat Cement [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [I AUGERS [I HOSE EfPIPE El MUSHROOM CAP ❑3 feel below surface or feel below surface if>3 feel COMMENTS: See Table 1 of Work Plan for total depths of wells to be destroyed. Well DMW-5B also includes a 10" diameter conductor casing which will be over-drilled to depth and removed. 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 �wy1.ttv'v KlM4 Tille/Company Regional Manger/Cascade Drilling Print Name Dustin King Dale 8/1 612 0 2 3 DEPARTMENT USE ONLY Application Accepted By:� Dale Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilil /Site Information FA Name iiixir Oc , FAAddress W , FA# 0016 g 3 g PRO 0 FA PE 2a ( 0 WP Reviewed By Work Plan Dale ( 2,>?j C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Pemn Access Agreement eadAgensyAppoval MFR COM SICONDITIONS:O I U -/ Q)V A` ow (U � I" h 4-'s L CCmtdstc{or ('411Na HIaS rrr��-�-f�%nC K ltnC�a(�{�-� � Ins (v D�% -F}r-n�Gs VIP TYPE PE SC IFEE INFO JAMT RENInTED1 CH/1ECK# RECV'D BY ATEo� WELL PERMIT# E# I A Permit 90 ! 44 x I� CCGlj� 2 V, p0 "t s oo LC 7 1868 E. Hazelton Avenue I Stockton, Calif rnia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 M JA N-20-23 1 6C? 'L^Z-g If ^ = Site Mitigation Well Permit Application