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=�DUIN SAN JOA UIN Environmental Health Department to COUNTY 1° P'f 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 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 AdvancedGeo , Inc. License# 1063765 Phone 800-511 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 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 ❑ HOLLOW STEM BORING DEPTH 20 Feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERORIVEN DIA, OF BOREHOLE 2 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 2 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge ozone) ❑ HAND AUGER GROUT SEAL DEPTH Entire TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs B54 and B55 GROUT SPECIFICATIONS Portland Type 11 and not more than 6 gallons/94 Ito 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 24t Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 DEPARTMENT USE ONLY Application Accepted By: Date Issued : .�/�/zo 22 Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name FA AddressZZ �� q FA# d X33 g PR# o `1 02 FA PE WP Reviewed By �� Work Plan Date � I Zp ��le ►, d .11 '� C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Workers Comp Waiver ❑ Encroachment Permit Access Agreement I11ead Agency Approval AMFR COMMENTS/CONDITIONS : LO JjV F WP TYPE PE SC I FEE INFO AMT IREMiTTED1 CHECK# I RECV'D BY (� DANE WELL PERMIT# INVOICE# Permit Z_l 313 $ 152 x (' � � C UV I Z / o, w Poo , 3 27' 1868 E . Hazelton Avenue StocktonCal , ifornia 95205 T 209 468-3420 F 209 464-0138 1 * ;js A , = EHD 29-01 04-04-07 Site Mitigation Well Permit Application