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SANdOAQUIN Environmental Health Department —COUNTY l SI1 „a�Y' Greatness prows 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 1031 E. Church St. City/State/Zip Stockton, CA 95205 Phone NIA Cross Street S. Union St. APN 15126035 Property Owner' Matias Jaime Lopez& Sosa. Maria Mercedes Rubio Phone (209) 649-8532 Address City/StatelZip C-57 Contractor Cascade Drilling Chris Tatum License# 1058336 Phone 510-772-0841 Address 3459 Collins Ave City/State/Zip Richmond, CA 94806 ConsultantiSub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: *Note: OffsHe Bodngs/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 11 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMaler) O HAMMERIDWVEN DIA.OFBOREHOLE 225inches ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOF CASING: ❑STEEL [I PVC ❑ OTHER ® SOILBORING 2 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes ❑No-Boring Die: Casing Ole: Casing Depth: ❑ INJECTION(IJrswaa 0zme) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: [I AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Mad we too DepN is 30 t) / w •� WELL/SOIL BORING IDs 10-B1S0,10-B2SO GROUT SPECIFICATIONS neat cement (C(/y� /5 � 444r— cewa -t: air bill 0 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION Ae@THOD: (CHECK ALL THAT APPLY) ;S 0.or pq,, /"'"` #WELLS TO BE DESTROYED [I OVER-BOREDIAMETER of_inches to depth of feel r GG I e. WELL IDs ❑PRESSURE GROUT To depth of feet below sudace GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [I AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel COMMENTS: DPT drilling of two 11-feet deep soil borings for environmental soil sampling. Analysis to include TPH-GRO, TPH-DRO/RRO, and CAM-17 metals. 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 BU Manager / Cascade Print Name Chris Tatum � Date 7/6/2023 E ARTMENT USE ONLY 2 Application Accepted By: Date Issued: 'f / t AO Grout Inspection By/Dates: �- f Destruction Inspection By/ aces: Facilit /Site Information -�g FAName FA Address th FA# Q `� PR# *+g FA PE Z 5 O WP Reviewed By I Work Plan Date .4?oT,2 &Yiwl j 7 0C-57AUthteizationfor Otherto Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Enaoachmenl Permit ss Agreement ❑Lead Agency Approval FR COMMENTS/CONDITIONS: rD✓i a ds ^n Vol)? RL 04 J~ t �b i;N s C WU( -. WP TYPE PE I SC ji FEE INFO JAMT REMiTTED1 CHECK# I RECV'D 4Y I DATE WELL PERMIT# INVOICE# Permit qo 3 i X Z, CG fi u1 P q�- 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 IF 209 464-0138 1 jC2h com S EHD 29-0104-20-23 Cc— I /50 9 17— +n Site Mitlgntim Well Pemmt Application