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SAN JOAQUIN Environmental Health Department <br /> (\ L'I COUNTY <br /> ..- / <br /> Greotness 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 10848 COpperopolls Rd City/State/zip Stockton, CA 95215 Phone 707-694-6027 <br /> Cross Street S. Patton Ave APN 103.110.06 <br /> Property Owner* Doug MacArthur Phone 209-910-9635 <br /> Address 10848 Copperopolis Rd 10 d1( 5 S`I)City/state2lp Stockton, CA 95215 <br /> C-57 Contractor Cascade Environmental License# 1058336 C-57 Phone 510-478-0858 <br /> Address 3459 Collin Ave. city/statelzip Richmond,CA,94806 <br /> Consultant/Sub-contractor Citadel EHS License# 1046421 Phone 707-694-6027 <br /> Address 102 Mill St City/State/Zip Grass Valley,CA,95949 <br /> CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUhLBER INSTALLATION TYPE CONSTRUCTION SPIFQFICATIONS <br /> MONITORING 3 HOLLOW STEM BORWG DEPTH 0 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapur/Water) ❑ HAMMERiDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICJ(NESS SCh 40 2" PEOFCASING: ❑STEEL DPVC ❑ OTHER <br /> ❑ SOIL BORING [I PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes No Berirg Dia: Casing 0ia: Casing Depth: <br /> ❑ INJECTION IA"Soame.O,.1 ❑ HAND AUGER GROUT SEAL DEPTH F0--g-1 TREMIE TYPE <br /> xTTOOyBE(aUSED: []AUGERS ❑HOSE PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? <br /> ATION - neat cefnent, �Jll-�JLPry rated <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS y <br /> TAlmr . - 'K r"E3' CTIO MET O�CH ALL THAT APPLY) <br /> � 202q <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS (I EXPLOSIVES From_to—feet below surface <br /> TREMIE TYPE TO BE USED El AUGERS [I HOSE El PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <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 /> Signed I7IA41,en1 K.LKA Title/Company Regional Manager/Cascade Drilling <br /> Print Name Dustin King Date 6.19.24 <br /> DEPARTMENT USE ONLY ,/ <br /> Application Accepted By: Date Issued: 20 2q- <br /> Grout Inspection By/Dates: 20 <br /> Destruction Inspection By/Dates: <br /> Facllit /Site Information <br /> FAName l0/WAt µN S;jL FAAddress 10 ri}2 (OpeerWa rs FA# 1 PR# <br /> FA PE I <br /> -Z Gt 60 WP Reviewed By VJ I Work Plan Date 2 Z /� 0 2 <br /> G57 ❑C57AuthaimVnf"othuto Sign Permit ❑Workers Comp ❑Workers Camp Waver ❑Enaoehment Permit ❑Access Agreement KLead Agency Approval FR <br /> COMMENTS/CONDITIONS: RvJQCS{ I,e fte— o'r*� � 141. , Cf {ft r—t-MvE. r �Y�l Gf;avt- roMf <br /> r-f-moval ) o-F MW s v✓ /10 1 an'j,e-r IA s e f-U�G� rs re.ac�K ; <br /> ryrtik 3 .SNP %'h s m4 - clerk ,xA ; s :0—�, <br /> WP PEI PE I SC I FEE INFO AMT REMrITTED CHECK# RECV-D BY DATE WELL PERMITS#{c� INVOICE# 71 <br /> Permit 2RO 313 $162 x 3 4 g b C C � � 2S av W? 2 00 C) O 1 <br /> eC # 1 8 35 $ So 1 SR 2`toO2.86 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> THE)29-017-01-2023 Ai' zgoof. 16 Site Mitigation Well Permit Applicegon <br />