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AN Q Environmental Health Department COUNT Y Greatness grows 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 , Job Address SIDEWALK NEAR TO 2025 Old Spanish Drive City/State/Zip Stockton /CA/95206 Phone ( 925 ) 278 - 8688 Cross Street Oxwell Drive APN Nearest APN is 163 -750 -40 (for 2025 Old Spanish Dr . ) Property Owner* City of Stockton Phone (209 ) 937 -8212 Address 425 N . EI Dorado Street City/State/Zip Stockton /CA/95202 C -57 Contractor PeneCore Drilling License# 906899 Phone ( 530 ) 661 -3600 Address 220 N . East Street city/State/Zip Woodland/CA/95776 Consultant/Sub-Contractor Geosyntec Consultants, Inc . License# Phone ( 925 ) 278 -8688 Address 1340 Treat Boulevard , Suite 208 City/State/Zip Walnut Creek/CA/94597 CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits Please see comment below TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 feet IX BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 3. 25 inch ❑ MULTIPLE CASINGS ❑ MULTI - LEVEL WELL CASING DIA X SOIL VAPOR PROBE 7 ❑ 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 ❑ HOSE ® PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SO ] LBORING IDs GROUT SPEC ] FICATIONS Neat Cement 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 COMMENTS : Phase see attached maps and fi ures Pres ntinq exact locgtion where soil vapor probe is planned to be installed , in the City of Stockton ' s sidewalk near to the residence at�2025 Old Span sh Drive , tockton . An Encr�achm nt Permit has b� eeen applied for frgm l e Cit of Stockt n , and the Permit A plication is attached , Geosyntec will present the Encroachment Permit to SJCEHD once it is receive from e City of �tockton (expected f�y August 10 . 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 . Signed /` a4 n Title/Company Senior Consultant , Geosyntec Consultants Print Name Ron Gestler Date July 15 , 2022 EPARTMENT USE ONLY � 1 Application Accepted By : zoo 1, Date Issued : O Grout Inspection By/Dates : t � Destruction Inspection By/ Dates : Facilit /Site Information FA NameFA Address `' lot� �' FA# 0 PR# FA PE a � 0 WP Reviewed By Work Plan Date ❑ C-57 -57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ncroachment Permit ❑ Access Agreement ead Agency Approval MFR COMM ENTS/CO ( TIONS : , ` ss �cvt �I�► t -� L� Q, �/ 0e GrIG''0 o�G �► � '+� W a- n o� roJ 'L � b � � r Cad l�I'� u�� C�-S Kgt I� Co C PE E C E IN C # RECV' D BY D TE WELL PERM ( # INVOICE# + WP TY P S FEE FO AMT REMITTED CHE K wrooli; 2TPermit $ 152 x ' 5 I 1868 E . Hazelton Avenue Stockton , California 95205 T 2C 468 - 3420 68 - 34 0 F X09 464 - 0138 www . sjgov, org /ehd EHD 29-01 06-28-21 � ite Mt��eII Permit Application