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p s one SAN JOAQUIN Environmental Health Department ofo t!: ._ --- COUNTY — f, ,i . •, `, �,. .. � rrrrftnes > ./ ro : r5 hr. rr: . 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 * Gertrude A . Bentz Family TrustMargo Bentz4vers , Trustee Phone 209-483-7285 Property Owner Y , g Address 4750 Lagorio Rd . City/State/Zip Stockton , CA 95215- 1811 C-57 Contractor NSA 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 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE [I EXTRACTION (VaporMater) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE inc [I MULTIPLE CASINGS El 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: NIA Casing Dia: NIA Casing Depth: NIA ❑ INJECTION (Air Soarae. Ozone) ® HAND AUGER GROUT SEAL DEPTH 9' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 0 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes IBJ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ 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 heroylertify thatI m auth rized to complete this application and that the work will be done in accordance with San Joaq n Cou r inanse Codes and Standards, and all other applicable California laws . Signed Z !' Title/Company Ground Zero Analysis , Inc. Print Name Gregory Stahl , PG 5023 Date May 9, 2019 DEPARTMENT USE ONLY Application Accepted By : 9&��+ ` Z&6LV: Z Date Issued : G _ 7 Zcr/9 Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name &5afe(44 FA Address I i3 w elnuh�► FA# ot:> Zr3a0 PR# OSS/ Sd9 FA PE Z 9 So WP Reviewed By a �E� Work Plan Date (� 3 _ i ❑ G-57 ❑ G57 Authorization for Other to Sign Permit [Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement [] Lead Agency Approval 21AFR COMMENTS/CONDITIONS : WP TYPE PE SC FEE INFO JAMT REMITTED1 CHECK# I RECV' D BY I DATE = WELL PERMIT# INVOICE# Permit Zjv6 "o15f3 $ 152 x z, j 304 000 .i0014 3 f tv 7S 1868 E . Hazelton Avenue I Stockton , California 95205 T 209 468-3420 ( F 209 464-0138 1 www . sjcehd . com EH909-01 -1152 % 3 tI ' 19 Site ilPermit Q61K aa, . Zo3523 640P50 (0 ��