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.:`I 1 (-10141 C ?`'a :. 't:?Y S AKJOAQUIN Environmental Health Department I i COUNTY Gtctliriess cirow here. 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. Cal Trans ROW - See Comments Section below for approximate locations 209-601-5074 Job Address MALo,r a* 0 C4 j; Stockton, CA 95203 3 -�' rr�..7 City/State/Zip Phone Cross Street S. Califomia Street APN None Property Owner* Cal Trans, District 10, Joe Valdez Phone 209-601-5074 Address 1976 E. Dr. Martin Luther King Jr. Blvd. City/State/Zip Stockton, CA 95205 C-57 Contractor Gregg Drilling License# C57-1044456 Phone 925-313-5800 Address 950 Howe Road Citylstate/zip Martinez, CA 94553 Consultant/Sub-Contractor Ground Zero Analysis, Inc, License# PG #9716 Phone209-5224119 Address 1172 Kansas Avenue City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ AtONITORING ❑ HOLLOW STEM BORING DEPTH 125 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (VaporMlater) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE 1.5 Inches ❑ MULTIPLE CASINGS ❑ MULTILEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: []STEEL ❑ PVC ❑ OTHER ® SOIL BORING 15 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Oepth ❑ INJECTION (Nr Sparge Ozonol ❑ HAND AUGER GROUT SEAL DEPTH 125 ft TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE EI PIPE ❑ OTHER ❑ `OTHER: GROUT SEAL PUMPED? ® Yes []No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING 10s CPTA2, CPTA3 &CPT -14 GROUT SPECIFICATIONS Neat Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑OVER -SORE 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 COMMENTS: CPT Locations: CPTA4: Under HWY 4 overpass N of E. Lafayette St. just W of S. America St. CPT -12: Approx 100' NE of S. Stanislaus St. CPTA3: SE Corner of Washington St. certify thaq� am thorized to complete this application and that the work will be done in accordance with San Joa[� in C untynrd;inance Codes and Standards, and all other applicable California laws. Signed Print N Stahl Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: 1 10 Title/Company Vice President Ground Zero Analysis, Inc. Date 02,— I �1— �,L�'.- FA Name V ��y' Z�2)jc� yj/.� �N FA Address �U �> , LR FA PE b O WP Reviewed By ❑ C-51 C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver COMMENTS/�OiVi91TtONS:(� f ttx,� oe. v 1868 E. Hazelton Avenue j EIiD 29-01 06-28.21 Stockton, California Worts Plan Date roactunentPermit ❑Access Agreement ead Agency Approval 4! �� 468-3420 209 464-0138 Site Miti{ 00 �so� vvww.sjgay.org m Well Permit Application