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SAN J OAQU I N 7:nvicfonmenLai Flsal�ch Depar noen-t --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 615 East Main Street City/State/Zip Stockton, CA 95202 Phone 209-937-8893 Cross Street North American Street APN 149-180-070 Property Owner' Creative Education Support Org LLC Phone N/A Address 4719 Quail Lakes Drive Suite G 237 City/State/Zip Stockton, CA, 95207 C-57 Contractor Slagle Drilling Corp. License# 1046151 Phone 916-363-9355 Address 11345 Trade Center Drive Suite 450 City/State/Zip Rancho Cordova, CA 95742 Consultant/Sub-ContractorAdvancedGeo,Inc. License# 1063765 Phone 209-467-1006 Address 837 Shaw Road City/State0p Stockton, CA 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 1 E9 HOLLOW STEM BORING DEPTH 40 ® BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 8" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Soaroe. Ozonel ❑ HAND AUGER GROUT SEAL DEPTH 16' TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE ® PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 FI) WELU SOIL BORING IDs TBD GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs sack 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 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 Godes and Stanaaras, ana an ower appncaole aranrorma yaws. Signed�/�, Title/Company SENIOR GEOLOGIST/A.G.I. Print Name Daniel Villanueva Date DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued: 3/25/2021 Grout Inspection By/Dates: \ (f y Destruction Inspection By/Dates: F '1" I /S't I f ation act r FA Name e norm Main Street Investments FA Address 22 E. Weber Ave. Rm 301 FA# FA0024288 PR# PR0542297 FA PE 2960 WP Reviewed By JW Work Plan Date 2/27/2021 EI C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver []Encroachment Permit [3 Access Agreement ❑ Lead Agency Approval [3 MFR COMMENTS/CONDITIONS: Submit report/results of finding to EHD per SJC Well Standards 13.7.2. WP TYPE PE SC FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2901 313 $152 x 152 1 152 1 ,, Y!',' 13%25'21 WP0041866 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 tAnArw.sjcena.com EHD 29-0109-01.17 Confirmation Number: 122727777 SR0083462 SheMiligalionWell Permit Application