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L SAN QA QQ N Environmental Health Department COU NTY Greatness groNs 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 1604 Tillie Lewis Drive City/State/Zip Stockton , CA 95206 Phone 209-983-1111 Cross Street West Charter Way APN 163-360- 180-000 Property Owner* Breit Stockton Industrial Park LLC Phone 916-246 -2120 Address PO Box #A3879 City/State/Zip Chicago , IL 60690 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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 1 ❑ 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-8 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 29A� Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 DEPARTMENT USE ONLY Application Accepted By : kvzlno Date Issued : �� Grout Inspection By/ Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name (Mf ,� ±FAAddress 2Zr FA# Z 3 3PR#FA PE Reviewed By Work Plan Date ZQZO k1� -57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement `s ead Agency Approval MFR COMMENTS/CONDITIONS : A Ai0Ter 4/' V ` le taAam4 S 13 • 'T . Z WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# I RECV' D BY DATE WELL PERMIT# > INVOICE# Permit Za 0 3 3 $ 152 x S ZT. 0 91 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 46M4201 F 209 464 - 0138 1 www . sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application