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1- SA N J OA Q U I N Environmental Health Department r`.- COUNTY SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 West Benjamin Holt Drive City/State/Zip Stockton CA 95207 Phone Cross Street Pacific Ave and Inglewood APN PropertyOwner" County of Stockton and City of Stockton public right of way Phone Address See attached map City/State/Zip C-57 Contractor Gregg Drilling LLC License# 1044456 Phone 925-313-5800 Address 950 Howe Rd City/State/Zip Martinez/CA/94553 Consultant/Sub-Contractor Geosyntec Consultants Inc Address 3043 Gold Canal Drive, Suite 100 License# City/State/Zip Rancho Cordova/CA/95670 Phone 916-637-8048 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 80' (CPT), 140' (EW) ® BOLTED TRAFFIC BOX ❑ STOVE PIPE ® EXTRACTION (VaporlWater) 1 (water) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE 2" (CPT), 1 t" (EW) ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SCH 80 TYPE OF CASING: 10 STEEL is PVC ❑ OTHER Steel screen, pvc casing ® SOIL BORING 7 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: 11.. Casing Dia: 6" Casing Depth: 140' ® INJECTION (Air Soaroe. Ozone) KMN04 ❑ HAND AUGER GROUT SEAL DEPTH 0 - 80' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE ❑ OTHER ® OTHER: sonic GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs CPT -22-06 through CPT -22-12, GEW-0368 GROUT SPECIFICATIONS Type II -V 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 PREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with 'Joaquin County Ordinance Codes and Standards, and au otner appucame cai forma laws. Signed Title/Company Project Geologist - Geosyntec Consultants Print Name Jamie Purcell Date 6/17/2022 Application Accepted By: Grout Inspection By/Dates: 4�17 6u Destruction Inspection By/Dates: j yatZZ — DEPARTMENT USE ONLY f 19 ZZ- G .,, -;- r7 ;t / Date Issued: G ( ( 2 0 (_ ()S�N !y� /- �JL fC� "-( ZG (-L AJ3s " il3o1 LZ FAName (�11(p ��'(!,r FA Address jy� �0 FA# Q 2 `3 Q Q PR# FA PE 0 WP Reviewed By Work Plan Date / '—+ /7-2 ❑ C-57 57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit Access Agreement Lead Agency Approval MFR COMMENTS/ ONDITIONS: 0i6 all ire4,,u epic, aAd- 16 r Y2V D Ca b M t -t -S .(r roy►'1:� y 6-� S c.(�--1'v�n be-�p re -b e Jc n n ✓lJo `in t� o1� 1 c1 T r ti o w WP TYPE I SC FEE IINfFO AMT REMITTTED CHECK# RECV'D WELL PyEjR�MIT# INVOICE# Permit QPE 2-I �� 13$152 x "i- O -BrY V % /DATE'' FJ {��t!�G W '"f 3115 sF_009tslfs o 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 04-04-07 Site Mitigation Well Permit Application