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S A N J 0 A Q U I N Environmental Health Department COUNTY . i 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 1502 N. EI Dorado Street City/State/Zip Stockton, CA 95204 Phone Cross Street Sperry Avenue APN Property Owner* City of Stockton Phone Address City right-of-way, south side of Sperry Ave City/State/Zip Stockton, CA 95204 C-57 Contractor Gregg Drilling LLC License# 1044456 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor GHD Services, Inc. License# Phone 530-558-1921 Address 4080 Plaza Goldorado Circle, Suite B City/state/zip Cameron Park, CA 95682 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �$MONITORING _D$ HOLLOW STEM BORING DEPTH 83 fbg 5(BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2 inches ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS echarli rle 4n TYPE OF CASING: ❑STEEL N(PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes (RNo Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 64 fbg TREMIE TYPE TO BE USED: X AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? X Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs MW-23 GROUT SPECIFICATIONS Portland Type 1/II neat cement and 5%bentonite 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 COMMENTS: 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 ljC� Title/Company Staff Geologist/GHD Services, Inc. Print Name Ryan Bast Date 11512021 DEPARTMENT USE ONLY Application Accepted By: Aaron Gooderham cac>` Date Issued: 01/22/2021 Grout Inspection By/Dates: �U (4 12Co I Destruction Inspection By/Dates: Facilit /Site Information FA Name Former Unocal Facility No.4409 FA Address 1502 N. EI Dorado Street FA# 23037 PR# G,� C, FA PE WP Reviewed By Aaron Gooderham Work Plan Date July 21,✓2020 ❑C-57 XC-57 Authorization for Other to Sign Permit X Worker's Comp ❑Worker's Comp Waiver XEncroachment Permit ❑Access Agreement XLead Agency Approval XMFR COMMENTS/CONDITIONS: When placing the grout seal: all ground water must be displaced from the augers before the augers can be used as a tremie pipe. WP TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE WELL PERMIT# j INVOICE# Permit 2901 313 $152, 1 1 $152.00 1 CARD I AG 01/07/2021 WP0041599 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Confirmation Number: 118942567 Site Mitigation Well Permit Application