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� craUiMS A N.DJ O A Q U I N Environmental Health Department COUNTY ° Greotness 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 180 East Weber Avenue Cross Street Weber and Hunter Property Owner* Judicial Council of California Address 455 Golden Gate Avenue C-57 Contractor Pene Core [ Address 220 N. East Street Consultant/Sub-Contracto Address 2020 Challenger City/State/Zip Stockton/Califomia/95202 Phone (209) 992 - 5555 APN City Sidewalks (encroachment permit being processed) Phone (415) 865 - 4200 City/State/Zip San Francisco/California/94102 License# 906899 Phone 530-661-3600 City/State/Zip Wood lands/Cal ifomia/95776 r Ninyo & Moore Geotechnical & Environmental Sciences License# 697063 Phone 510-343-3000 Drive , Suite 103 City/State/Zip Alameda/Califomia/94501 - CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 30 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (VaporMater) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE Approx. 3" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER No Casing SOIL BORING 4 PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE INNER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes [I No (Note: Maximum Freefall Depth is 30 Ft) WELL] SOIL BORING IDs B-2, B-3, B-5, and B-7 GROUT SPECIFICATIONS Tremi-g rout with neat 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 IREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE []PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: 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 91 Title/Company Senior Project Geologist / Ninyo & Moore Print Name Bryan A. Fong Date 11/19/2020 Application Accepted By: Grout Inspection By/Dates Destruction Inspection By/Dates: F�ril itvlCitn Infnrm Minn DEPARTMENT USE ONLY,_l J Date Issued: /,1- 7 �w S ZALS l- FA Names �u� FA Address - W �6� FA# 1 PR# FA PE - L CI WP Reviewed By V Work Plan Datebc / ❑ 6-57 P16,57 Authodzadon for Other to Sign Permit orker's Comp ❑ Worker's Camp Waiver Vncroachment Permit ❑ Access Agreement Lead Agency A proval P<FR COMMENTS/CONDITIONS: A C oil bo -pi 3, WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permits $152 x-17 S ,,. �� 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 Site Mitigation Well Permit Application