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S A N 3J O A Q U I N a J Environmental Health Department COU NTY— - Greotness t,rre. 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 760 Charter Way City/State/zip Stockton, 95206 Phone Cross Street S. Stockton Street APN 163_23 _2.3 Property Owner* Mario A Jaques Phone (209)482-1191 Address 13286 Willow Glenn Rd- City/State/zip Stockton, CA 95206 C-57 Contractor Salem Engineering Group,Inc License 970772 Phone (559)271-9700 Address 4729 W. jacauelyn Ave- City/Statelzip Fresno,CA 93722 Consultant/Sub-Contractor TEG Northern California License# 706568 Phone (916)853-8010 Address 11350 Monier Park Place City/State/zip Rancho Coedova, CA 95742 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE In ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER J`I SOIL BORING _-la PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae,Ozone l ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE III PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOILBORINGIDs SB-1 t 1�Ugh SB-5 GROUT SPECIFICATIONS neat cement 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 El PIPE (�PIPE El MUSHROOM CAP El feet below surface or feet below surface if>3 feet COMMENTS:114- 5p j;jr jAk -1 o �T1 D *(er66 cay. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �I� fL/ San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed_ 56.7` L Title/Company Senior Project Manager Print Name Shannon Lodge Date 8/27/2.019 /^ � DEPARTMENT USE ONLY Application Accepted By: ' V Date Issued: Grout Inspection By/Date :, 3 2 Q Destruction Inspection By/Date , Facilit /Site Information ,� FA Name fo �r��{ jl�Xi� FA Address W6 C40(6- FA# 00 l PR# 6/ � FA PE 2 0 :�-�j2✓�• WP Reviewed By Work Plan Date R/Z� q C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMMMMENTS/CONDITIONS: �C ..� kale. y irkt�tc- b k- C ' wo s' a J• o r > WP TYPE PE SC FEE INFO AMT REMITTED CH/E1CK# RECV'D BY AT p�f WELL PERMIT# INVOICE# Permit ZW f 3 $152 x 145 C.C, 3 1zi1 W o o 400-31 1868 E. Hazelton Avenue I Stockton, California 95205 ( T 209 -3420 F 209 464-0138 j www.sjcehd.com EHD 2M1 08-01-17 51112-108110 lite Mitigation Well Permit Application