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a Ikk+ .SAN )JOA U I N LjY COUNTY Greatness grows here. Environmental Health Department 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) 9534697 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 6006 N Highway 99 E Frontage Road City/State/Zip Stockton CA 95212 Phone NA Cross Street Hammer Lane APN 087 Property Owner' Carol Scannavino Phone 209-931-1599 Address 6006 N State Route 99 E Frontage Road Clty/State/Zip Stockton CA 95212 C47 Contractor Geocentric Drilling Inc License#k C-57:1073146 Phone g1s_:304_2665 _ Address 1980 S River Rd, Ste E City/State/Zip West Sacramento CA 95691 Consultant/Sub-Contractor Parsons ATTN: Cynthia Oppenheimer License# PG 9415 Phone 925-3244895 Address _2121 N California Blvd 500 City/State/Zip Walnut Creek CA 94596 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WEll1BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 854 ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERNRIVEN 0►A OF BOREHOLE g ink ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING _�_❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia Casing Dia: in'h: ❑ INJECTION (,aur Spays Ozor»I ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑HOS IPE �a% [I OTHER © OTHER Sonic GROUT SEAL PUMPED? ❑ Yes .❑ No (Note: Maximum Freefall Depth is" t) ��/ NEW SOIL BORING IDs GROUT SPECIFICATIONS /V ea..'e C DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE COMMENTS: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet I hereby certify that I am authorized to complete this application and that the work will be done In accordance with S Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed IV Title/Company Project Manager/Parsons Print Name Cynthia Oppenheimer Date 7/6/2022 Application Accepted 8y: Grout Inspection By/Dates: Destruction Inspection By/Dates: Date Issued: V WP TYPE PE Permit Authorization for Other to Sign Permit ❑Workers Comp ❑ Worker's Comp Waiver ❑Encroachment Permit ��lccess IONS::�j �V�S�'A� e,r�—" i►A C�t'hi.$�' Cy��`�otkek SC I FEE INFO d56�c r REMITTED CHEWRECV'D BY Lam✓ rI Agreement P fea�d Agency Approval INVOICE* � S40 �j�'® i 1868 E. Hazelton Avenue �Stoc ton, Call ornia 95205 � T 209 468-3420 � F 209 464-0138 � www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application