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SHIN JOAQUIN Environmental Health Department ---COUNTY—- Greatness grows 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 10848 Copperopolis Rd City/state/zlp Stockton, CA 95215 Phone 707-694-6027 Cross Street S. Patton Ave APN 103.110.06 Property owner. Doug MacArthur I Phone 209-910-9635 Address 10848 Copperopolis Rd j'd gox 5 3 5 ity/state/zip Stockton, CA 95215 C-57 Contractor Cascade Environmental License# 1058336 C-57 Phone 510-478-0858 Address 3459 Collin Ave. ctty/state/zip Rlchmond,CA,94806 Consultant/sub-contractor Citadel EHS License# 1046421 Phone 707-694-6027 Address 102 Mill St Citylstate/Zip Grass Valley,CA,95949 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS { jc'V\ CL A ,,-SeP- ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ffOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapormateN ❑ HAMMERNRNEN DIAOFBOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS 11/ NG: STEEL M OnfR ❑ Teflon ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING r3--I Yes 09No Boring Dia: Casing Ola: Casing Depth: ❑ INJECTION(PTraoxas ozone/ HAND AUGER GROUTSEAL DEPTH �-" TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER If OTHER: GROUT SEAL PUMPED? ❑es ENO ee: WELUSOILBORING IOs SVP-1 thrOtigh SVP-3 GROUT SPECIFICATIONS 5.5.4.5'2/12 Monterey Sand with probe at 5, 4.5-3.5 dry bentonite 3.5.0' cement grotrt.with traffic rated well box. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: rcHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of feet WELLIDs []PRESSURE GROUT Todeptho( feelbelowsurface GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [I AUGERS [I HOSE ❑PIPE [I MUSHROOM CAP ❑3 feet below surface or feel 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 Sa/ry/,�I aquin County Ordinance Codes and Standards, and all other applicable California laws. Signed ////J/i�a/�K'ZG/G—p!/.7!/��f Title/Company Citadel EHS Project Scientist Print Nameigne c1ViJ 1-GII$ Date 07/03/2024 EPARTMENT USE ONLY •� /� Application Accepted By: Date Issued: Grout Inspection By/Dates: 777 Destruction Inspection By/Dates: Facilit ISite Information �yp FA Name �Q,r' n sr-! FA Address (17� 1 6 ;S FA# PR# FA PE WP Reviewed By Work Plan Date 2 2 E 2 d 2 G57 ❑C57Aulhodmtionfor OthertoS4n Penft ❑Workers Canp ❑Wor I keess Goomp Wavier ❑EncroarhmentPermlt ccess Agreement Lead Agency Approval FR COM TS/C -5ONDITIONS: v Fs yK V S"L_- Q C UA'L e e ',-D, �,� r• , P . ore rd v I VIP TYPE I PE I SC J FEE INFO AMT REMITTED CHECK# I RECVD BY DATE WELL PERMIT# INVOICE # Permit 2105 313 ZX 1 172 CC 20 SW 43 P Z�1-o00 0 leIt133o 'T6 s Z (too2g 1868 E. Hazelton Avenue I Stockton, California 95205 I T 2U9 400-o4�v I F 209 464-0138 I www.sjcehd.com EHD 29-01 7-01-2023 Site Mi9gatlon M11 Permit Appliragon