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SAN JOAQUIN Environmental Health Department 'COUNTY— 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 Near 800 West Church Street City/State/zip Stockton, CA 95203 Phone NA Cross Street S. San Jose Street APN 14523012 Property Owner' The City of Stockton Phone (209) 937-8212 Address 425 N. El Dorado St. City/state/Zip Stockton, CA 95202 C-57 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 BodngsANells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPICPT) CONDUCTOR CASING ❑Yes ❑No Boning Dia: Casing on: Casing Depth: I ❑ INJECTION&spree ormal ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: [I AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER GROUTSEALPUMPEDP ❑Yes [I No (Note:Maximum Freefall Depth is 30 Ft) WEW SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ❑OVER-BORE DIAMETER of 6 inches to depth of 30-71 feel WELLIDs DMW-GA, DMW-6B, DMW-BWT ❑PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS Portland Cement-Type I/Neat Cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE FrPIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel COMMENTS: See Table 1 of Work Plan for total depths of wells to be destroyed. 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 p V— �A Title/Company Regional Manager/Cascade Drilling Print Name Dustin King Date 8/1612023 DEPARTMENT USE ONLY Application Accepted By: Date Issued: / ?A ZZ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name S-EOC_(e FAAddress I t00 (AI, FA# 1 00 PR# FA PE LGt WP Reviewed By Work Plan Date q-1/ C/Z O G57 [I G57Authotization 1"Otherto Sign Permit ❑Workers Comp ❑Workers Comp Waiver Wncroachment Pemdl ❑Access Agreement Agency Approval gKfJL COMRENTS/CONDITIONS: C/�,YC _ r _ rl�tr,rn r• L / 2 2 •7 ,e !1 O WP TYPE PE SC I FEE INFO AM, T REMrrTEDj CH�ECCK# I RECV-DD BY GDATE •7 WELL PPERMMM INVOICE# Permit jZqoZ1R31s16u I to/4 :o WR400't`t4��¢ 1868 E. Hazelton Avenue I Stockton, Califg�nia 95205 T�f209 4 8-3420 I F 209 464-0138 1 W4vw�jcehd.6om EHD 29-01 N-20-23 t 6 a 4 'Z-tN 4-s a f,0 I+) + l(7q 47 2r4 i?,d9etion W�il�Pemtit ApplicOon v�4 / Z� C��