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�Pnui�c'z VANsJOAQUIN Environmental Health Department ' COUNTY 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 ' nn c -- --. _ X110 E Weber Ave) City/State/Zip Stockton/Califomia/95202 Cross Street Weber and Hunter APN 149-020-12 (110 E Weber Ave) Property Owner* Judicial Council of California Address 455 Golden Gate Avenue City/State/Zip San Francisco/California/94102 C-57 Contractor Pene Core Drilling License# 906899 Address 220 N. East Street City/State/Zip Woodlands/California/95776 Consultant/Sub-Contractor Ninyo & Moore Geotechnical & Environmental Sciences License# 697063 Address 2020 Challenger Drive , Suite 103 City/State/Zip Alameda/California/94501 Phone (209) 992 - 5555 Phone (415) 865 - 4200 Phone 530.661.3600 Phone 510-343-3000 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 30 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (VaporlWater) ❑ 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 Cl SOIL BORING 1 ® PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Soame.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) WELU SOIL BORING IDs B-6 WP TYPE GROUT SPECIFICATIONS Tremi-grout with neat cement DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED N/A WELL IDs GROUT SPECIFICATIONS DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface PREMIE 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 Bn�r..c��- 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�nili}vlSi4c Infnr•m Minn DEPARTMENT USE ONLY Date Issued: -1 L -1712Z-11 FA Name ` �' FA Address L,` FA#�'p V ? PR# FA PE WP Reviewed By Work Plan Date ❑ C-57 -57 Authorization for Other to Sign Permit orker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit Access Agreement Lead Agency Approval 1dMFR COMMENTS/CONDITIONS: w'� l ` I5 v� -D Atis �3D►'a-e.� WP TYPE PE SC FEE INFO #MT REMITTED CHIECP RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 31-5 i, 1 qse 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com EHD 29-0108-01-17 Site Mitigation Well Permit Application