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RECEIVED SAN J O A Q U I N Environmental Hea l!Apment ENVIRONMENTAL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICktOks ERV ICES 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. 240 Lincoln Center:858 West Benjamin Holt DrivOo W. U v?u)0 Stockton,CA,95207 916 637-8320 Job Address City/State/Zip Phone Cross Street Pacific Avenue APN 097410§ _�9 Property Owner* Lincoln Property,Ltd. Phone Address 374 Lincoln Center City/State/Zip Stockton,CA,95207 C-37 Contractor PeneCore Drilling License# 906899 Phone 530-661-3600 Address 220 N.East Street City/State/Zip Woodland,CA,95776 Consultant(Sub-Contractor Geosyntec Consultants License# Phone 916-637-8048 Address 3043 Gold Canal Dr.,Suite 100 City/State/Zlp Rancho Cordova,CA,95670 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Bonngs/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20 feet ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ® HAMMERIDRIVEN DIA OF BOREHOLE 4- ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE MUD ROTARY CASING THICKNESS NIA TYPE OF CASING: ❑STEEL ❑PVC 10 OTHER ration ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air span,omrt ❑ HAND AUGER GROUT SEAL DEPTH 5 it bgs TREMIE TYPE TO BE USED: ❑AUGERS❑HOSE ISI PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? El Yes ❑No (Nate:Maximum Freefall Depth ws 30 Ft) WEU SOIL BORING IDs TSG-001 through TSG-010 GROUT SPECIFICATIONS Grout to ground surface with anchoring cement. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED N/A ❑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: Install a multiple depth soil vapor probes.Up to 5 probes will be installed.Maximum boring depth of 50 feet bgs. I hefeby certify that I am authorized to complete this application and that the work will be done In accordance with San Jo a uin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Senior Principal Hydrogeologist,Geosyntec Consultants Print Name Arthur Fo Date 12/29/2020 DEPARTMENT USE ONLY l A 3/2a zl Application Accepted By: Date Issued: Grout Inspection By/Dates: ` Destruction Inspection By/Dates /✓� i-444 Fa I It l i e Information _ FA Name Lk�Ca C� d FA Address W�PMptkL 1 91 f r FA# C�� PR# 0S-5 FA PE u Z 960 WP Reviewed By l C,- 4t v itis�(,�,� Work Plan Date 1�.0-57 C-57 Authonzalbn for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ad Agency Approval MFR COMMENTSICONDITIONS: VCf1rov lro,n. ►'IQdL t� ,! 1 �ti � �h S�t �rPdxS ala Or Prrflr 6� O A4k{'. vor��r P/�bGS yY1 'f G�brLn�lo�4�d 4�'t?.,� d U A•v�Cl �cih ori a C r i h WP TYPE PEc SIC FEE FO AM REMITTED CHECKS RECV'D BY DATE WELLPER`III INVOICE# �_I Permit QQO J �` �J $152 x 3 �� Q0 1 t-3� 94 ��/2 00 U 11 J 1" 1868 E. Hazelton Avenue ( Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 1/4/Zi Site Mitigation Well Permit Application