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AN aN Environmental Health Department COUNTY 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 ❑ STOVEPIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN 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) WELL/ SOIL BORING IDs B54 and B55 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 Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 DEPARTMENT USE ONLY e Application Accepted By : Date Issued : , ,A 2,2 Grout Inspection By/ Dates : 7j Destruction Inspection By/Dates : Facilit /Site Information FA Name FA Address a4 � t4 CL FA# d 7,33 Oa IPR# ® 5L0 g FA PE WP Reviewed By dVj Work Plan Date qI �#,1 ► d � O '� C57 ElC-57 Authorization for Other to Sign Permit ElWorker's Comp El Workers Comp Waiver ❑ Encroachment Permit Access Agreement Dead Agency Approval MFR COMMENTS/CONDITIONS : ar, y0 9T rky WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit ZQ O S1 313 1 $ 152 x304'2, c C 14/onA2 D0 � 3 Zwfr c:M4 1) ,nrrf G•Aiq` 1 �jr z a Z 9 o g a 5 400 F 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 -3420 F 209 464 - 0138 ij e9d . corn EHD 29-01 04-04-07 Site Mitigation Well Permit Application