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Npr c� SAN JOAQUIN Environmental Health Department COUNTY cgLP. 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 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 434 E.Dr.Martin Luther King Jr.Blvd City/State/Zip Stockton CA 95203 Phone Cross Street California Street APN 167-150-310-000 Property Owner* Phone Address City/State/Zip C-57 Contractor Gulf Shore Construction Services Inc. License# 964224 Phone 916-939-4117 Address 3382 Fitzgerald Rnad City/State/Zip Renrhn['nrrinva,CA Afi742 Consultant/Sub-Contractor Wayne Perry Inc. License# 300345 Phone 714-826-0352 Address 8281 Commonwealth Ave City/State/Zip guena Park,CA 90821 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporNVater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparse,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 5 ®OVER-BORE DIAMETER ofd inches to depthof 30-35 feet WELL IDs MW-1 MW-2 MW-3 MW-4 MW-5 0 PRESSURE GROUT To depth of 35 feet below surface GROUT SPECIFICATIONS AJ e aP ❑EXPLOSIVES From to feet below surface 'Will tremie TREMIE TYPE TO BE USED ®AUGERS ElHOSE ElPIPE ❑MUSHROOM CAP El3 feet below surface or feet below surface if>3 feet f J COMMENTS: MW-1 to be abandoned by pressure grouting. Cc k C 5 5�D(�✓t (�—Itsy. _ MW-2,MW-3,MW-4,and MW-5 to be abandoned by overdrilling. 1 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 Project Manager/WPI Print Name Mi'rwurena Date 9/29/20 PARTMENT USE ONLY 7 Application Accepted By: Q Date Issued: v I b Grout Inspection By/Dates: 1:2I n 2 on 101y'lZo Destruction Inspection By/Dates: Facilit /Site Information FA Name r S FA Address 13 T Dry �� FA# O O Z5v - PR# Q �17 FA PE 2 V WP Reviewed By 1 / , Work Plan Date 1 L ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMM ENTS/CONDITIONS: t +p J"% -ry q 3,5 s3 M N d— �"�W 30 6 41-s " Q irtut � l FeV w WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit l�v 3{ $152x_` om 0 to T -I OO , r0. {I 888 � alelton Ave i�iVni STockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 6(iti2gatio5 e11 1 pp kation