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SANJOAQUIN Environmental Health Department �t9 �'�' COUNTY � r�.e .1 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 1610 N. EI Dorado Street City/state/zip Stockton, CA 95204 Phone Cross Street Sperry Avenue APN 127-080-100-000 Property Owner* Parvez Ahmed Phone Address 2109 East Fremont Street City/State/Zip Stockton, CA 95205 C-57 contractor Gregg Drilling LLC License# 1044456 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Cons ultanUSub-contractor GHD Services, Inc. License# 17-00062639 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 WIELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS [MONITORING 2 IR HOLLOW STEM BORING DEPTH (1) 118';(2)83' U BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2 inches ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS schedule 40 TYPE OF CASING: ❑STEEL Ig PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes [No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone l ❑ HAND AUGER GROUT SEAL DEPTH(1)99' ; (2)64'TREMIE TYPE TO BE USED: [RAUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs (1)MW-25 GROUT SPECIFICATIONS Portland Type 1/11 Neat rement and 5%bentonite (9) -26 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. SignedTitle/Company Staff Geologist/GHD Services, Inc. Print NamW Ryan Bast Date 1/5/2021 DEPARTMENT USE ONLY Application Accepted By: Aaron Goode a 'r Date Issued: January 11, 2021 Grout Inspection By/Dates: F ZeZ) Destruction Inspection By/Dates: Facilit /Site Information FA Name Former Unocal Facility No.4409 FA Address 1502 EI Dorado Street FA# 23037 PR# FA PE WP Reviewed By Aaron Gooderham Work Plan Date July 21, 2020 ❑C-57 KC-57 Authorization for Other to Sign Permit XWorkeesComp ❑Worker's Camp Waiver ❑Encroachment Permit X Access Agreement XLead Agency Approval MFR 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 DATE WELL PERMIT# INVOICE# Permit 2901 1 313 $152 x 2 1 $304.00 CARD I AG 01/05/2021 WP0041600 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2M1 08-01-17 Confirmation Number: 118833891 Site Mitigation Well Permit Application