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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / u p0 B65 ) <br /> 24 Hours Advance Notice Required For All Inspections ( AT <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 /> fro s tu5 <br /> Job Address 1050 S. Diamond St.(nger) pt►aYess „+naea' city/state/zip Stockton, CA 95205 phone <br /> Cross Street Dr. Martin Luther King Jr Blvd �s AyrAPN 155-320-150 <br /> Property Owner- Diamond Foods Phone <br /> Address 1050 S. Diamond St. city/state/zip Stockton, CA 95205 <br /> C-57Contractor Cascade Drilling License# 1058336 Phone 916-638-1169 <br /> Address 3006 Duluth St, city/stateimp West Sacramento, CA 95691 <br /> ConsultantfSub-ContractorATC Group Services LLC dba Atlas Technical License# Phone 209-579-2221 <br /> Address 1117 Lone Palm Ave., Suite 201 B City/statelzip Modesto, CA 95351 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 36 ft. ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER(DRIVEN DIA,OFBOREHOLE 3 In_ ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER <br /> ® SOILBORING —2—® PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ®No Ferr Da: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Ar Beene ozmel ❑ HAND AUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: [I AUGERS [I HOSE 91PIPE <br /> ❑ OTHER ❑ O ER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELUSOIL BORING IDS 0 GROUT SPECIFICATIONS nP-at CP.linTent <br /> DESTRUCTION WZYRK E NMEME7 DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <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 El EXPLOSIVES From—to—feet belowsurface <br /> TREMIE TYPE TO BE USED El AUGERS [I HOSE ❑PIPE [I 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 it Title/Company Project Manager <br /> Print Name Matthew Tolbert Date 7/29/2024 <br /> DEPARTMENT USE ON Y /I // <br /> Application Accepted By: raw. C. / Date Issued: `"!� <br /> Grout Inspection By/Dat <br /> Destruction Inspection By/Dates: <br /> Facilit (Site Information <br /> tt 40 92S _ <br /> FAName �iAn1QY� d t' o0 S fA Address (� Q FA# PR# <br /> FA PE O WP Reviewed By I Work Plan Date <br /> 0C-57 7Authorization for Other to Site Permit ❑Workers Gomp ❑Workers GwpWaiver ❑Encroachment Permit ❑AaessAgmemenl KLeadAqencyApproiyai MFR <br /> COMMENTSIC C6ITIONS: <br /> WP TYPE I PE I SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# <br /> Permit 29053 (3 jswrx �, 1 3 'L4 Cc s' W 24-w lTI <br /> Cr-IFI $ 6 Z4 1 IZ3 SR2400 3$2- <br /> 1868 E. Hazelton Avenue l Stockton, California 95205 l T 209 468-3420 l F 209 464-0138 l www.sjcehd.com <br /> EHD 29-017A1-2023 Site Mitigation Well Permit Applica9on <br />