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SAN JOAQUIN <br />Greatness grows here. <br />Environmental Health Department <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 129 South Grant Street City/State/Zip Stockton/CA/95202 Phone 209-521-2133 <br />Cross Street East Market Street <br />149-220-200-000 <br />Property Owner* Goodwill Industries <br />Address 928 12th Street, Suite 200 <br />C-57 Contractor AdvancedGeo, Inc. <br />Address 837 Shaw Road <br />ConsultantlSub-Contractor AdvancedGeo, Inc. <br />Address 837 Shaw Road <br />qp N <br />Phone 209-521-2133 <br />City/State/Zip Modesto/CA/ 95354 <br />License# 1063765 Phone 209-467-1006 <br />City/State/Zip Stockton/CA/95215 <br />License# 1063765 Phone 209-467-1006 <br />City/State/Zip Stockton/CA/95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OFWELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 Feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 1.5 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑x SOILVAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone) ❑x HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs SV1 through SV3 GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: �cHECK AI_L 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 >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />� � San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print Name <br />Jasleen Singh <br />Title/Company AdvancedGeo, Inc. <br />Date 08/16/2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By: Jeffrey WOng Date Issued: 8/27/2021 <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: y ` /" l Z. Z <br />Facilitv/Site Information <br />FA Name <br />Goodwill <br />Stockton No.2 <br />FA Address <br />129 S. Grant <br />F/� <br />FA0026743 <br />PR# <br />pR0009241 <br />FA PE <br />2950 <br />WP Reviewed By <br />JET <br />Work Plan Date <br />8/18/2021 <br />C-57 <br />ElC-57Authorization for Other to Sign Permit <br />El Worker's Comp El Worker's Comp Waiver El <br />Encroachment Permit El Access Agreement El Lead <br />Agency Approval K MFR <br />COMMENTS/CONDITIONS: <br />Submit a copy of the results to EHD per SJC <br />Well Standards 13.7.2 <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D <br />BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />2905 <br />313 <br />1$152 x 3 <br />1456 <br />cc <br />JW <br />8/24/2021 <br />WP0042484 <br />Confirmation #: 2094671006 SR0084149 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 1 F 209 464-0138 1 vwvw.sjgov.org/ehd <br />EHD 29-01 06-28-21 Site Mitigation Well Permit Application <br />