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1 oN&UIN . SAN JOAQUIN Environmental Health Department l k 41 + ` . COUNTY Greatness grows here . SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON - REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 1029 - 1045 North EI Dorado Street City/State/Zip Stockton , CA 95205 Phone NA Cross street East Magnolia Street APN 013 - 904 - 002 - 000 Property Owner* Freedom 123 , LLC Phone NA Address 2960 Poinsettia Drive City/State/zip San Diego , CA 92016 C- 57 Contractor Environmental Control Associates , Inc . ( ECA) License# 695970 Phone 916 . 417 . 6858 Address 3011 Twin Palms Drive City/State/Zip Aptos , CA 95003 Consultant/Sub -contractor Partner Engineering and Science , Inc . License# NA Phone 559 . 907 . 7502 Address 1544 Eureka Road , Suite 180 City/State/zip Roseville , CA 95661 CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 25 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVENX DIA . OF BOREHOLE El MULTIPLE CASINGS ❑ MULTI LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes LX No Boring Dia; Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH U N K TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? XYes El No ,(Note, Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs B1 1 R21 B3 GROUT SPECIFICATIONS rout via County requirements . Neat Cement via TremIP Pipe DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLYI # 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 : No well to be created , grab water sampling at terminal depth . Soil gas probe installed within each borehole her y ertify that 1 am authorized to complete this application and that the work will be done in accordance with an Joaquin County Ordinance Codes and Standards, and all other applicable California laws . Signed Title/Company Project Geologist - Partner Engineering and Science Inc. Print Name Laure Hinch Date 12 - 13 -2021 DEPARTMENT USE ONLY Application Accepted By : JEFFREY WONG Date ed : 12/23 /2021 Grout Inspection By/Dates : Is � Z Destruction Inspection By/Dates : Facilit /Site Information FA Name FREEDOM 123 , LLC FA Address 1029 - 1045 EL DORADO FA# FA0026929 PR# PR0547377 FA PE 2950 WP Reviewed By JW Work Plan Date 11 / 10/2021 ❑ C-57 W C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval IN MFR COMMENTS/CONDITIONS : Submit report/results to EHD per SJC Well Standards 13 . 7 . 2 NOTE : SUB SLAB SAMPLING NOT PART OF THIS PERMIT WP TYPE PE I SC I FEE INFO JAMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit 2905 1313 1$ 152 x 2 1 304 CC I JW 12/22/2021 WP0042870 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468 - 3420 1 F 209464 - 0138 1 www . sjcehd . com EHD 2MI 08-01 - 17 confirmation number 136346356 Site Mitigation Well Permit Application