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S A N sd 0 A O U I N Environmental Health Department COUNTY-- , °' Greatness grows her:_ 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 applicatiogl is mgde in complianc(LmthLSan Jo uin CQumy Develop en Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. '�-.CJ 7 ;,iT.t..✓V-u�'l �. `' C 1. ,- �1� � Job Address p^1Ar^^^'^^^-`^ -` ^u# 6 ^F t r lmopf S. iity/State/Zip Stockton CA 95267 Phone rnv�rcaaraacvi vraaan nvc. , Cross Street Fremont ST. & Grattan Ave. APN Property Owner" City of Stockton Phone Address City/State/zip C-67 Contractor Gregg Drilling, LLC License# 1044456 Phone 925 313 5800 Address 950 Howe Road city/state/zip Martinez, CA 94553 ConsultanVSub-Contractor Atlas Technical License# Phone 209 579 2221 Address 1117 Lone Palm Ave., Suite 201 B City/State/zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 2 t0 90'.4 to 120' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 6 ® PUSH POINT(GP C CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air S°arae.Ozone) [IHAND AUGER GROUT SEAL DEPTH i'1 U' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IN PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS Neat Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL.THAT APPLY1 #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑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: See Atlas' Subsurface Investigation Work Plan dated December 21, 2022 1 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 Senior Geologist/Atlas Print Name Todd Hafner Date 5/22/25 P DEPARTMENT USE ONLY _ Application Accepted By: i Date Issued: Zrl 2�7, C �n Grout Inspection By/Dates: S TA ' Destruction Inspection By/Dates: J0.4 Facili /Site Information E4( 0/y F01J FA Name FA Address O, 7 _. l�f,r ru v•.,•r FA# ��t) .Z(u 2 P '+� , �� FA PE �Llt 110 WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: / l ( yy�• > WP TYPE PE SC FEE INFO AMT REMITTED DATE WELL PERMIT#, r INVOICE# Permit 'L L1 O, �(5 $172 x -�(, 2 mSI2 1G12S 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 08-01-2024 Site Mitigation Well Permit Application