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.r S A N J O A Q U I N Environmental Health Department 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 N 69-a 3 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 149-0901 t5-0 I Property Owner' Sharon Olivarez Phone 209-481-5360 Address 540 W Scotts Avenue City/State/Zip Stockton,CA 95203 C-57 Contractor Cascade Drilling License# 9 10, D 59,3 A_Phone 925-849-6970 Address 1641 Challenge Drive City/State/Zip Concord,CA 94520 C �j �n s 9/3a/Z i Consultant/ ub-contractor Ground Zero Analysis, Inc. License# PG 5234-Raynold 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 WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 6 ft/8 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE rl EXTRACTION(Vapor/Water) _ _❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA N/A i i 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? 19 Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS 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 ❑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 Sr.Operations Manager/Cascade Drilling Print Name Christopher Tatum Date August 29 2019 DEPARTMENT USE ONLY Application Accepted By: Date Issued: 0 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information n FA Name ' N4/ FA Address ��0 S S . I= �' rn�Q FA# (g � Z SSZ1 PR# p, ^�0 7f FA PE 2 O WP Reviewed By /� VV �� Work Plan Date 9/07 [9 C-57 ElC-57Authorization for Other to Sign Permit ❑Worker's Comp El Worker's Comp Waive ncroachment Permit ❑Access Agreement [I Lead Agency Approval El MFR i COMMENTS/CONDITIONS: NbM .yli ti my S re1 �'M�„ +-p J WpX9 S ,Q O V,On WP TYPE I PE I SC I FEE INFO JAMT REMITjTED CHECK# RECV'D BY DATE WELL PE,�RMIT# INVOICE# Permit Zoo�j $152 x � 3Q If 13;Z613 (1 O q 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