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i SAN AOU Enviironm ( ntal Health Departm en IL 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 ) 953u7697 For INSPECTIONS I 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 800 West Church Street City/State /Zip Stockton , CA , 95203 Phone NA Cross Street - SAN JOSE AP 14523012 / 14523013 Property Owner' Newark Group Inc revised per Scott Little 2 /4/2022 Phone ( 614 ) 226 -4530 Address 3200 HighlandS Parkway , Suite 300 City/State/Zip Smyrna , GA 30082 C -57 Contractor En Probe Environmental Drilling Services License# 1012248 Phone: ( 530 ) 589 =2019 Address _P . O . Box 6093 City/State /Zip Oroville , California 95966 Consultant/Sub •Contractor AECOM License# NA Phone ( 916 ) 207-3053 Address 2020 L St , Suite 400 City/State/Zip Sacramento , CA 95811 CONSTRUCTION WORK TO BE PERFORMED : Note : Offsite Boring0Nells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STPD BORING DEPTH 10 , ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapori'Alaler) ❑ HAWAERDRIVEN DIA, OF BOREHOLE 241 ❑ MULTIPLE CASINGS ❑ AIULTI•LEVEL YYELL CASING DIA ❑ SOIL VAPOR PROBE ❑ NIUD ROTARY CASING THICKNESS NSA TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER VSOIL BORING 4 2' PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia : Casing Dia : Casing Depth: ❑ INJECTION ( Air Sparae, O;onel ❑ HAND AUGER GROUT SEAL DEPTH TREPAIE TYPE TO BE USED. ❑ AUGERS ❑ HOSE Q�PIPE ❑ OTHER ❑ OTHER : GROUT SEAL PUMPED ? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Fl) WELLI SOIL BORING IDs SB2022 -01 t0 SB2022 - 04 GROUT SPECIFICA7ION' S Portland Cement-Type 1 / 11 Neat Cement DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD ! iCHECI< 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 TREPAIE TYPE TO BE USED [] AUGERS ❑ HOSE [:] PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet befog' 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 fSan�.J d County Ordinance Godes and Standards, and all other applicable California laws . SignedZL � _ Title/Company � [J -Z y ' Print Name 1 1 Date DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued : 2 /4 /2022 Grout Inspection By/Dates ' 2 Z Ll1 Destruction Inspection By/Dates : Facilit !Site Information FAName GREIF STOCKTON FAAddress 800 W CHURCH FA9 FA0016638 PRS PR052478 FA PE 2960 WP RevieNed By JWWork Plan Date 1 /27/22 C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ 'A'orker s Comp E] Worker' s Gornp Waiver ❑ Encroachment Permit ❑ Access Agreement Lead Agency Approval MFR COMMENTS/ CONDITIONS : Submit report/results to EHD per SJC Well Standards 13 . 7 . 2 Note : EnProbe ' s C57 permit # 1012248 expires on 3 /31 /22 . This boring permit is effective only if the C57 is still active WP TYPE PE SC FEE INFO AMT REMITTED1 CHECK# RECV' D BY DATE WELL. PERMIT# INVOICE # - ---- - . .... . -- _ . _ _ - - - - ----- -WP004295 Permit 2903 313 152 x 3 456 cc1131122 , confirmation # : 138180258 Sr0084 $ 36 1868 F . Hazelton Avenue I Stockton , California 95205 1 T 209 468 - 3420 1 F 209 464 - 01 38 1 WWW . sjgov . org / elid EHD 29 .01 06-28 -21 Site A1IHgallon Well Pernit AppHcatlan