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SANJQQ UIN Environmental Health De artmentQ p 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 535 South Center Street City/State/Zip Stockton / CA / 95203 Phone Cross Street Hazelton Avenue APN 14907035 Property Owner* Pacific Gas and Electric Company ( Anne Conner PG & E ER PM ) Phone 925 - 415 - 6331 Address P . O . Box 7640 City/State/Zip San Francisco / CA / 94120 C -57 Contractor . Gregg Drilling License# 1044456 Phone 925 - 313 - 5800 Address 950 Howe Road City/State/Zip Martinez / CA / 94553 Consultant/Sub -Contractor CH2M HILL License# 733633 Phone 303 - 771 - 0900 Address 9191 S . Jamaica Street City/State/Zip Englewood / CO / 80112 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 ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA . of BOREHOLE ❑ 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 Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑THOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note : Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) 5195 / 115 # WELLS TO BE DESTROYED Two ( 2 ) ® OVER-BORE DIAMETER of 10 inches to depth of feet WELL IDs MW - 21 and MW - 23R ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat cement from TD to 21 ❑ 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 : MW - 23R , PVC conductor casing to 10 ' bgs is surrounded by grout . Proposed to be left in place . See attached boring logs for well construction . 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 Codes and Standards, and all other applicable California laws . SignedJUOf AS.042n6en Title/Company operations Manager Print Na e Jake Wilson Date 3/16/2022 DEPARTMENT USE ONLY Application Accepted By : � Date Issued : 12*63 / o2 G. Grout Inspection By/Dates :, Destruction Inspection By/Dates : Facilit /Site Information FA Name FA Address I FA# D 0 ZC.I. 24+ j FA PE j �' �� WP Reviewed ByWork Plan Date 57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreementead Agency Approval N& FR RSA COMMENTS/CONDITIONS : . � Can � $ o wrs � � P C 3 /r D /Zv 2Z LL0n, V.0 ►-�-4y o�,n l Irl �+✓ - Z I vL M h/ - 2v3R �,�rt b @ n /P.�L J n o { ; .. C tS� Pte' PTs l �' y �{ed ► ! 2 Z Z o i l �.(�w, .� WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit � QQ 3 j 3 $ 152 x0 ] ; I CC � LA/ 0 0 L 11 'rK yl' D 6 �+ 3 SA00 $ 5 0 ZS 1868 E . Hazelton Avenue Stockton , California 95205 1 T 09 46M4201 F 209464 - 0138 www . sjgov . org /ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application