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r SAN J O A O U IN Environmental Health Department ! COUNTY 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 330 West Harding Way City/State/Zip Stockton CA, 95202 Phone (408) 660-7473 Cross Street N Van Buren Street Property Owner* Batra, Atul Kumar & Suman Address 91 Los Altos Drive C-57 Contractor AdvancedGeo, Inc. Address 837 Shaw Road Consultant/Sub-Contractor Slagle Drilling Corporation Address 11345 Trade Center Drive APN 137-080-010-000 City/State/Zip Hollister, CA 95023 License# 1063765 City/State/Zip Stockton, CA 95215 License# 1046151 City/State/Zip Rancho Cordova, CA 95742 Phone (408) 660-7473 e (209) 467-1006 Phon Phone (916) 363-9355 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 ElEXTRACTION (Vapor/Water) ElHAMMERIDRIVEN 2960 DIA, OF BOREHOLE ❑ SOILVAPOR PROBE El MUD ROTARY CASING THICKNESS ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes F] No El INJECTION (Air Sparge, Ozone l EIHANDAUGER GROUT SEAL DEPTH El OTHER El OTHER: GROUT SEAL PUMPED? El Yes ❑ No WELL/ SOIL BORING IDs SC I FEE INFO GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION # WELLS TO BE DESTROYED Two (2) ®OVER -BORE WELL IDs MW -2 and MW -7 ❑ PRESSURE GF GROUT SPECIFICATIONS Portland type cement to surface grade ❑ EXPLOSIVES TREMIE TYPE TO BE USED 171 AUGERS 171 HOSE ®PIPE ❑ MUSHROOM C Monitoring well MW -2 will be overdrilled to 46 feet below surface grade and surface grade. Both wells will be backfilled to surface grade with Port I hereby certify that I am authorized to complete this application anc San Joaquin County Ordinance Codes and Standards, am PR# PR051892 FA PE 2960 land ty I hereby certify that I am authorized to complete this application anc San Joaquin County Ordinance Codes and Standards, am Signed L c� Print Name Evan Schmidt Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: (50 Facilitv/Site Information JEFFREY WONG Title/Compal Date Febru DEPARTMENT USE ONLY Date Issued: 3/26/2021 FA Name 1868 E. Hazelton Avenue � Stockton, California 95205 1 T 209 46&34201 F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 Confirmation Number: 121053829 HESS-DUBOIS, FORMER FA Address 348 W HARDING FA# FA0014223 PR# PR051892 FA PE 2960 WP Reviewed By JW Work Plan Date 12/28/2020 ❑ C-57 E5kC-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit Access Agreement ❑ Lead Agency Approval [5t MFR COMMENTS/CONDITION& Note: part of payment is Submit report to EHD per SJC Well Standards 13.7.2 deposited to this well permit instead of the original SR0083455 WP TYPE I PE SC I FEE INFO JAMT REmiTTED1 CHECK# I RECV`D BY I DATE I WELL PERMIT# INVOICE# Permit 2902 313 $152 x 4 1 608 CC MK/J 2/23/2021 WP0041867 SR0083455 Site Mitigation Well Permit Application