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sAN �oAQuiN �ouNTY- Greatness grt�ws here. Environmental Health Department SITE MITIGATION WELL &BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 1002 N. Holden Rd City/State/Zip Linden, CA 95236 Phone 209-948-0333 cross street F __ M I (tn n R d APN 105-110-310 Property Owner* Stockton East Water District Phone 209-948-0333 Address 6767 E. Main Street City/State/Zip Stockton, CA 95215 c -s7 contractor Cascade Drilling License# 1058336 Phone 916-638-1169 Address 3flCl nuluth Street city/state/zip West Sacramento, CA 95691 Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUM ER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING �❑ HOLLOW STEM BORING DEPTH 1,B5O� ❑BOLTED TRAFFIC BOX ®STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 12.25" ®MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA 2.5�� ❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS SCh. 8O TYPE OF CASING: ❑STEEL ®PVC ❑OTHER ❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 5O� TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs GROUT SPECIFICATIONS Neat Cement �94 Ib bag�5-1 O gal Water DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE COMMENTS: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface n MUSHROOM CAP f—I 3 feet below surface or feet below surface if >3 feet 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 � �� Title/company Project Manager, Cascade Drilling Print Name Jlm Whitley Date 1/6/21 DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Date Issued FA Name � EW, " Q I FA Address � (�0 � N � I � � FA# {�� 0 2�2 g o PR# P�Q�j 1.1 �y � 3 FA PE � � � � WP Reviewed By �A,�/10. {�n�`'� Work Plan Date � - � � C-57 ❑ C-57 Authorization for Other to Sign Permit � Worker's Comp ❑Worker's Comp Waiver' `❑° Encroachment Permit °� Access Agreement ❑Lead Agency Approval � MFR COMMENTS/CONDITIONS: � w /�1l S m,wj 1 � � .-�'�-�t/'�� OV�PiY" �Y' i �! � �y � r C✓��G�S� i t/�/S lo -e �-� � I VC-��1� S�iu-��n c� o eS �o�T �/hef e� Cru vr�' y S �o�c� o�rr�S - WP TYPE PE SC FEE INFO AMT REMITTED CHECK# ' RECV'D BY DATE WELL PERMIT# INVOICE# Permit ��J �V� $152x � � �jp��OD �°�4 O � ��(2°ZI VVP©� �� 7,%� 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjcehd.com O�' � Site Mitigation Well Permit Application EHD 29-01 08-01-17 � � aZ t/ Z1�2