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AN Q Environmental Health Department <br />G' �i COUNTY-- <br />._, � <br />�rFOF�'` 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 1049 E. March Ln. city/State/zip Stockton, CA 95210 Phone <br />Cross Street West Lane <br />APN 104-080-04 3 $ ('b 141 f2, ' 1211 Z - <br />Property Owner* McDonald's Corporation Phone 503-867-3427 <br />Address 110 North Carpenter <br />c-57 Contractor Cascade Drillin <br />Address 3000 Duluth St <br />City/State/Zip Chicano, IL 60607 <br />License# 1058336 Phone 916-638-1169 <br />City/State/zip West Sacramento, CA 95691 <br />License# <br />Phone 209-579-2221 <br />Consultant/Sub-Contractor ATC Group Services LLC, dba Atlas Technical <br />Address 1117 Lone Palm Avenue, Ste. 201 B <br />Cit <br />y/state/Zip Modesto CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br />TYPE OF WPI <br />LIBORING <br />❑ MONITORING <br />❑ EXTRACTION NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />(Vapor/Water) <br />El SOILVAPORPROBE <br />ElSOIL BORING <br />❑ INJECTION (Air Sparge, Ozone) <br />EIOTHER <br />WELL/ SOIL BORING IDs <br />❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ HAMMER/DRIVEN DIA, OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED 1 <br />WELL In MW <br />-10 <br />GROUT SPECIFICATIONS neat cement <br />TREMIE TYPE TO BE USED ® AUGERS ❑ HOSE ❑ PIPE <br />COMMENTS. <br />Signed_ <br />Print Name <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />® OVER -BORE DIAMETER of 8 inches to depth of 65 feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <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 />6A 4 V At W Title/Company Regional Manager <br />Dustin Kinq Date 6.22.22 <br />Application Accepted By:d1� Date Issued: <br />DEPARTMENT USE ONLY <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facilit / <br />FA Name <br />FA PE <br />COMME <br />C-57 ❑ C-57 Authorization for Other to Sign Permit <br />FA Address I'Zp6 rl/�a,1r�� FA# d� Z3 ��'� <br />WP Reviewed By Work Plan Date <br />❑ <br />Worker'sComp E] Worker's Comp Waiver El Encroachment Permit ccess Agreement e <br />ONDITIONS: � I�� �cS� VC U ���s o���0�+ <br />l I <br />Agency Approval %FR <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � ww�n�.sjcehd.com <br />EHD 29-01 04-04-07 <br />Site Mitigation Well Permit Application <br />SIZo�B,�� <br />