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t �ulNCG2� SAN 10AQUIN Environmental Health Department Q \ y t ": COUNTY— IF CNUNTYIF/ Greatness grows hero . 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 WELL/BORING 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 SparaeOzone) ❑ HAND AUGER GROUT SEAL DEPTH 3Feet TREMIE TYPETO BE USED: El AUGERS El HOSE El 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 lb 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 Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 DEPARTMENT USE ONLY � 7 Application Accepted By: Date Issued : Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name ( a FA Address ZZ C Ar FA# 60 Z 3 38q PR# a 5 4 0 g p FA PE WP Reviewed By tAj Work Plan Date 57 ❑ C-57 Authodzafion for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver' ❑ R Encroachment Permit ❑ Access Agreement jLead Agency Approval MF COMMENTS/CONDITIONS : t . 6�I� ro M9 er4s V ) d 3tGm S 13 �. Z WP TYPE PE SC I FEE INFO JAMT REMiTTED1 CHECK# I RECV' D BY DATE WELL 1 PERMIT# INVOICE# Permit Za o f 3 ` 3 $ 152 x 5 2 V Z : C�-F rnna{Trv. ii- 7?2q o q IzooS �Z� O 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 09 468-3420 1 F 2094 4-0138 1 www , sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application