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L <br />e <br />SAK JOAQUIN Environmental Health Department <br />COUNTY <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 953-7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 846 W. Benjamin Holt Drive (see attached map) City/State/Zip Stockton, CA, 95207 Phone <br />Cross Street Pacific Ave APN 09741073 _32. 01 01 5 W • 32 Iq L <br />Property Owner* Lincoln Properties Limited Phone 209-478-9200 <br />Address 374 Lincoln Center City/State/Zip Stockton, CA, 95207 <br />C-57 Contractor Gregg Drilling LLC License# 1044456 Phone 925-313-5800 <br />Address 950 Howe Road City/State/Zip Martinez, CA 94553 <br />Consultant/Sub-Contractor Geosyntec Consultants Inc. License# Phone 916-637-8048 <br />Address 3043 Gold Canal Drive, Suite 100 City/State/Zip Rancho Cordova, CA 95670 <br />CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING <br />NUMBER <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING <br />❑ <br />HOLLOW STEM <br />BORING DEPTH 80 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) <br />❑ <br />HAMMER/DRIVEN <br />DIA. OF BOREHOLE 2 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE <br />❑ <br />MUD ROTARY <br />CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />® SOIL BORING <br />5 ® <br />PUSH POINT (GP/ CPT) <br />CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: <br />® INJECTION (Air Soarae.Ozone) <br />KMN04 ❑ <br />HAND AUGER <br />GROUT SEAL DEPTH 0.80 feet TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE <br />❑ OTHER <br />❑ <br />OTHER: <br />GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDS DIP -22-01 through DIP <br />-22-05 <br />GROUT SPECIFICATIONS Type II -V <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />r-1MUSHROOM CAP F13 feet below surface or feet below surface if >3 feet <br />I hereby certify that I am authorized to complete this <br />:'a Joaquin County Ordinance Codes and <br />Signed' <br />Print Name Jamie Purcell <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: i <br />Farilifv/Cifn Infnrmafinn <br />plication and that the work will be done in accordance with <br />indards, and all other applicable California laws. <br />Title/Company Project Geologist - Geosyntec Consultants <br />Date 6/1712022 <br />Date Issued: � [ Z q- la ?—a <br />(Y�/ <br />l aRntZ. In, ` hl� <br />FA Named <br />FA Address jAo A <br />FA# <br />�Q Z <br />PR# <br />FA PE <br />� q 60 I WP Reviewed By <br />Work PlajDatej <br />4❑C-57 <br />57 Authorization for Other to Sign Permit ❑Worker'sComp Worker's Comp Waiver C1Encroachment Permit <br />V4ccess AgreemeAgency Approval MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />I <br />PE <br />I SC <br />I FEE INFO <br />JAMT REMITTED1 <br />CHECK# <br />I RECV'D BY <br />I DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />$152 x 1+ <br />S <br />I Z:7 <br />r / <br />{ (Z <br />'^' <br />•" Poo 1t 34 i <br />SX00$�L_rj0 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />