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SAN f Q p Q U I N Environmental Health Department <br /> --------COU N T Y.-.__._ <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953.7697 For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 800 West Church Street City/State/Zip Stockton, CA, 95203 Phone NA <br /> Cross Street N/A APN 14523004 <br /> Property Owner' Newark Group, Inc Phone (614)226-4530 <br /> Address 3200 Highlands Parkway Suite 300 City/State/Zip Smyrna, GA 30082 <br /> C-57 Contractor En Probe Environmental Drilling Services License# 1012248 Phone (530) 589-2019 <br /> Address P.O. Box 6093 citylstate/zip Oroville, California 95966 <br /> Consultant/Sub-Contractor AECOM License# NA Phone (916)207-3053 <br /> Address 2020 L St, Suite 400 City/State/Zip Sacramento, CA 95811 <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10, ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2-3n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING'. ElSTEEL ❑PVC ❑ OTHER <br /> SOIL BORING _Rr PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Nr Sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS El HOSE [PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? []Yes ❑No (Nate:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs SB2022-01 t0 SB2022-04 GROUT SPECIFICATIONS Portland Cement-Type 1/II Neat Cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD! (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS ❑HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if 53 feet <br /> COMMENTS: <br /> I henodly certify <br /> n Jth aut a ed to q runty Ordinance cedes and application <br /> tand rds,and all other applicable and that the work ll be done In California laws.ante with <br /> Signed Title/Company <br /> Print Name Date -T ' Z�L Z <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By I Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITI ONS: <br /> WP TYPE PE I SC FEE INFO JAMT REMITTED CHECK#j RECV'D BY j DATE WELL PERMIT# INVOICE# <br /> Permit 152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 WWW.Sjgov.org/ehd <br /> EHD 29-0106-28-21 Site Mitigation Well Permit Application <br />