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SA NsJ OAQ U I N Environmental Health Department I_•-r. COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 1604 Tillie Lewis Drive City/State/Zip Stockton, CA 95206 Phone (209)933-0580 Cross Street West Charter Way APN 163-360-180-000 Property Owner* Breit Stockton Industrial Park, LLC Phone (224)257-4400 Address P.O. Box#A3879 City/State/Zip Chicago, IL 60690 C-57 Contractor Cascade Drilling License# C-57#938110 Phone (916)639-1169 Address 3000 Duluth Street City/State/Zip West Sacramento, CA 95691 Consultant/Sub-Contractor Condor Earth License# 732026 phone (209)234-0518 Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 and 30 feet❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ,VOIL VAPOR PROBE UD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER SOIL BORING 4—Y PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Ca g Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 2.5 fe_e� TREMIE TYPE TO BE USED: AUGERS [I HOSE [I PIPE [I OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs; B49A, B49B, B50A, and B50B GROUT SPECIFICATIONS g4lbs cement/5-6 gallons of water DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #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: 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 PG#6795/Condor Earth Print Name Inhn P I an _ Date 03/20/19 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: 4.,elJ Facilit /Site Information FA Name P. AAddress M yf'19 ./AV lee w FA# Z33Y 9 PR# 05Y.&Jra a FA PE 2 g4 p WP Reviewed By � A194 � Work Plan Date ❑C-57 la'C-57 Authorization for Other to Sign Permit (worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit [r�ccess Agreement ❑Lead Agency Approval ff&FR COMMENTS/CONDITIONS: O"�►,/�c�d $i, u i•�s C fc G/• WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2905- 3/3 $152x 3 X */5-(,•co is-w ? W14bQ3?1fyE 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application IVP2go3 - -�3A/S'zx.3 "d�� •co iSy® ^� s/�dli� —<-�f.,G-y