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SAN JOAQUIN Environmental Health Department r- � Y•1- COUNTY-- Greotness groes stere. 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 2050 East Fremont Street City/State/Zip Stockton,CA,95205 Phone 209-612-5573 Cross Street Laurel Street APN 153-130-030 Property Owner` Fremont Plaza Investments LP Phone 209-937-8444 Address 1050 East Fremont Street City/State/Zip Stockton,CA,95205 C-57 Contractor ADVANCEDGEO,INC. License# 1063765 Phone 209-467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 Consultant/Sub-ContractorADVANCEDGEO,INC. License# 1063765 Phone 209-467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 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 6.5 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 2 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,ozonel ❑ HAND AUGER GROUT SEAL DEPTH 3.5 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Free(all Depth is 30 Fl) WELL/SOIL BORING IDs VP-1,VP-2 GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs sack 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 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 SENIOR GEOLOGIST/A.G.I. Print Namev Daniel Villanueva Date 0411512020 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information p / FA Name Q C / FA Address -&5-0 �/ FA# o S-! (� PR# O L5 FA PE 1 q/_ WP Reviewed By l,v >` Work Plan Date _R) TF-D 14- [3 C-57 ❑G57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp✓Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COM EPFTSJCONDITIONS: U L w- ro( S / �� J,{� �I � f 3 , z Jrpl 'W ( z r I WP TYPE PE SCU FEE INFO AMT REMITTED CHECK# RECV'D BY QATE WELL PERMIT# INVOICE# Permit $152 x � l.i,l�. 3 �f 1868 E. r,-_elton Avenue I Stockton, California 05205 T 209 468-3420 1 5 209 6,+-v rou � id.co m EHD 29-01 08-01-17 iWeell P t Applat' rM " on