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Department SAN Environmental Health . -. C O U N E Y -- -- - I P' Greatness grows tie ; 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 401 South EI Dorado Street City/State/Zip Stockton/CA/95203 Phone 209-460-5000 Cross Street East Sonora Street APN 149- 062- 150 P I Property Owner* Gerald Jones of the Housing Authority of the County of San Joaquin Phone 209-460 -5000 Address 2575 Grand Canal Blvd City/State/Zip Stockton/CA/95207 C -57 Contractor Confluence Technical Services , Inc. License# 1035255 Phone 707-639-7709 Address 6821 8th Street City/State/Zip Rio Linda/CA/95673 Consultant/Sub -Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 to 25 feet bgs ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA , OF BOREHOLE 2. 25 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER x❑ SOIL BORING 8 El PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth : ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 DP- 1 through DP-8 GROUT SPECIFICATIONS Neat Cement Grout 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 I COMMENTS : DP- 1 through DP-5 borings are to 20-25 feet bgs . DP-6 through DP-8 are to 5 feet bgs . 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 Z.G4019& ( � Title/Company Geologist/ Condor Earth Print Name Luke Castle Date 2/ 18/2022 n DEPARTMENT USE ONLY Application Accepted By : Date Issued : nom" Grout Inspection By/Dates : i 17A L3 4LZ Destruction Inspection By/ Dates : Facilit /Site Information FA Name - 4 � > j : FA Address I� �.% � � I FA# , PR# '� e Lr FA PE WP Reviewed By �� ,l Work Plan Date ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMM ENTS/CONDITIONS : ;Vt l l " �'�' ( l t.� � 1 �+ �� if 1 �«rl "v c1� ' � 3 , �I WP TYPE PE SC FEE INFO AMT REMITTED CHErCK# RECV' D BY DA TE WELL WELL PERM/ IIT# INVOICE# Permit $ 152 x 1-f' �t Cl � / (1� yo6 3V 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 -0138 fi www . sjgov . org /ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application