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;Q'0fUtk``.�; SAN J OAQ U I N Environmental Health Department `�gtrronl'�� irEfliuc :.S grows lif'tf 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 1502 E. March Ln. City/State/Zip Stockton, CA 95210 Phone Cross Street West Lane APN 096-140-24 $ 00 1 9 1 , ' 2- . Zq 0 Z9 Property Owner" King of Central Valley 11 LP Phone Address PO Box 1547 City/State/Zip San Ramon CA 94583 C-57 contractor Cascade Drilling License# 1058336 Phone 916-638-1169 Address 3000 Duluth St. City/State/Zip West Sacramento, CA 95691 Consultant/Sub-Contractor ATC Group Services LLC,dba Atlas Technical License# Phone 209-579-2221 Address 1117 Lone Palm Avenue, Ste. 201 B City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapof/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMETER of 8 inches to depth of 55 feet WELL IDs MW-15 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS neat cement ❑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 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �`j ��,-� Sa, aquin County Ordinance Codes and Standards,and all other applicable California laws. Signed i(/ifL6l /[ilil2� Title/Company Regional Manager/Cascade Drilling Print Name Dustin King Date 6.22.22 DEPARTMENT USE ONLY � r2 L/ Application Accepted By: Date Issued: Grout Inspection By/Dates: A �t Destruction Inspection By/Dates: Facilit /Site Information �- FA Name r dY� FA Address Za a FA# D O '� �{ PR# D `> o9�� FA PE ZGt 6 Q WP Reviewed By r� Work Plan Date C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ii-Access Agreement _Lead Agency ApprovaEoMfR COM ENTS/CONDITIONS: WP TYPE PE sC FEE INFO AMT REMITTED CHECK#I RECV'D BY / JDATE WELL PERMIT# INVOICE# Permit Zao Z 3 3 $152 x 5�D8"5t-tS�- 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application