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IL ` � SAN J Environmental Health Department `"- _.: �l _a° COUNTY .. `r' 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 2245 West Charter Way City/State/Zip Stockton , CA 95206 Phone 209-983-1111 Cross Street Tille Lewis Drive APN 163-360- 170-000 Property Owner* Raymond Investment Corp . Phone 209-983 - 111 1 Address PO Box 567 City/State/Zip Stockton , CA 95201 C -57 Contractor Penecore Drilling License# 906899 Phone 530-661 -3600 Address 220 North East Street City/State/Zip Woodland CA 95776 Consultant/Sub -Contractor AdvancedGeo , Inc . License# 1063765 Phone 800-511 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 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 2 ❑ HOLLOW STEM BORING DEPTH 25 Feet ® BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 8 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Sch 40 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 3 feet TREMIE TYPE TO BE USED : ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs MW-6 and MW-7 GROUT SPECIFICATIONS Portland Type II and not more than 6 gallons/94 Ib sack 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 : 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 gv Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 IN 1111� D PARTMENT USE ONLY Application Accepted By : Date Issued : Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name �ar'rnQ,r FA Address7 45 WUkr4in I FA# 10 V Z33 89 1 PR# job 40 LIP22 FA PE O WP Reviewed By Work Plan Date of �82Z ,Ao�Lk""l 8/ ZZ C-57 ❑ C-57 Authorization for Other to Sign Permit Worker's Comp ❑ Worker' s Comp Waiver ❑ Encroachment Permit ❑ Access Agreement Lead Agency Approval14MFR COMMENTS/CONDITIONS : � � a{, a ��I � �- �/1 � , 1�� 1 �S 1 � • 2 � Z WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit l � l 131 > 1 $ 152 x 04 C 12 1 Z vjpbo3 z� 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 1 F 209 46 0138 1 www . sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application