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SA N 4,J 0 A 0 U I N Environmental Health Department COUNTY c9(1P�µNj! 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 y 6$ b 335 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 300 S California Avenue City/State/Zip Stockton, CA 95203 Phone 209-481-5360 Cross street Lafayette Street APN 149-09-501 1 Lt"go1$O I Property Owner* Sharon Olivarez Phone 209-481-5360 Address 540 W Scotts Avenue City/Stare/Zip Stockton,CA 95203 �� i 925-849-6970 C-57 Contractor Cascade Drilling Lic`nse# 9 t'U 1®.S$ 3 34 hone Address 1641 Challenge Drive City/State/Zip Concord,CA 94520 XP►-,-S R /30 7,-6 ZI Consult dub-Contractor Ground Zero Analysis, Inc. License# PG 5234-Reynold Kablanow Phone 209-522-4119 Address 1172 Kansas Avenue City/State/Zip Modesto,CA 95351 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 6 ft/8 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA N/A ® SOIL VAPOR PROBE —❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑STEEL 19 PVC ❑ OTHER SOIL BORING _® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? I&Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs GROUT SPECIFICATIONS Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY1 #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 [3 AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTSSv L4tI/IV a^2- l7�,rAt n wt&. I hereby certify that 1 am a1uthorized 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 Sr.Operations Manager/Cascade Drilling Print Name Christopher Tatum Date August 29 2019 DEPARTMENT USE ONLY / Application Accepted By: Date Issued: t to / 2 Grout Inspection By/Dates: Destruction Inspection By/Dates: ff Facili /Site Information n I (, FA Name ;t � �ja l� FA Address ��0 S Ir df,f * (= �' rnIQ FA# Q b Z SSZ1 PR# O s�'T'g�f FA PE Y`c/L 2 O WP Reviewed By /� �� (A]10C ��]Work Plan Date--an, / 9/,?� �q C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ncroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR i COMMENTS/CONDITIONS: NbM N/li ti �' "/S J u111M9 SJ p O V,O V� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2.9 ( $152 x � 3 o /�W _` 3 lq W o0 q0 / O 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application