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SAN 10AQUINp Environmental Health Department Crentnes , gro )vs 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 1323 W. Charter Way City/State/Zip Stockton , CA 95206 Phone 209 - 5224119 Cross Street S . Stockton St . APN 163 -230-050 Property Owner* Gertrude A. Bentz FamilyTrust Margo Bentzdvers , Trustee Phone 209483 -7285 Address 4750 Lagorio Rd . City/State/Zip Stockton , CA 95215 - 1811 C-57 Contractor N /A License# Phone Address City/State/Zip 209 -5224119 Consultant/Sub-Contractor Ground Zero Analysis , Inc. License# PG 5023 ; Greg Stahl Phone 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 9 reel ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE Inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NIA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 2 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING [] Yes ® No Boring Dia: N/A Casing Dia: N/A Casing Depth: NIA ❑ INJECTION (Air Soarae Ozone) HAND AUGER GROUT SEAL DEPTH 9 ' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes 9 No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs GROUT SPECIFICATIONS Grout to 1 foot bgs , fill in last 1 foot with native soil and/or exisitng surface 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 feel COMMENTS : I here ertify that I m auth razed to complete this application and that the work will be done in accordance with San Joaq n Cou x inanee Codes and Standards, and all other applicable California laws . Signed ,000000 Title/Company Ground Zero Analysis , Inc. Print Name Gregory Stahl , PG 502 Date May 9 , 2019 DEPARTMENT USE ONLY Application Accepted By: IIIIIII /VtXlP�h ` in,c�� Date Issued : Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name f�SS�ua�•� lrootlOk FA Address 1 i3 w � �urE�r FA# oo2 � 3va PR# OS5/ Soy FA PE 9 Sd WP Reviewed By Work Plan Date (� @3 .o.. 19 ❑ C-57 ❑ G57 Authorization for Other to Sign Permit [Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval BUR COMMENTS/CONDITIONS : WP TYPE I PE SC I FEE INFO JAMT REMITTED1 CHECK# I RECV' D BY I DATE I WELL PERMIT# INVOICE# Permit zgv5 7513 $ 152x2 a 36LJ000 3 ( w A44 "" - , cuj.� 39G7 ,� 1868 E . Hazelton Avenue Stockton , California 95205 ( T 209 468 -3420 F 209 464-0138 1 www. sjcehd . com QNK 004*� EHD 29-0108-01 -17 . 15Z K X 54 M+ (0 ` 30 ) 9 Site Miligalion ell Permit Application Z� -03 S 3 OCI 50 yc'