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SAN . J OA Q U I N Environmental Health Department hn COUNTY � ,_ ,��,•, ' Greatness grows here . 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 1200 Humphreys Street (see figures) I J � ( � City/State/Zip Stockton, CA 95203 Phone 209-946-0246 Cross Street See figures APN 16203007 Property Owner* Portof Stockton Phone 209-946-0246 Address 2201 West Washington Street City/State/Zip Stockton , CA 95203 C-57 Contractor Penecore Drilling License# 906899 Phone 530-661 -3600 Address 220 N. East Street City/State/Zip Woodland CA, 95776 Consultant/Sub-Contractor Geosyntec Consultants License# N/A Phone 5101t -836-3034 Address 1111 Broadway 6th Floor City/State/Zip Oakland CA, 94607 -+ 75 - 3 0 3 ZZ CONSTRUCTION WORK TO BE PERFORMED : * Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH Approximately 7 ft ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 3 .7 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELLCASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 2 ❑ PUSH POINT (GPI 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 Fl) WELL/ SOIL BORING IDs SS-8178-6A; SS-817B-7A GROUT SPECIFICATIONS Type 1/11 Portland Cement 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 COMMENTS : 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 �(�� {�(„�� ,� Title/Company SeniorGeologisUGeosyntec Consultants Print Name Kimberly Br ndt Date June 16 , 2022 MENT USE ONLY Application Accepted By: Date Issued : !/ Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name f� S ( � FA Address 0 FA# 00 �'> o O PR# 00 " � L �$ FA PE Z_( ( Q WP Reviewed By Work Plan Date ❑ C-57 G57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ead Agency Approval R COMMENTS/C ND TIONS : WP TYPE QPE Sc FEEINFOAMT REMITTED CH��ECK# RECV'D BY DATE � � )WELL PE'R1MIT# � ( INVOICE# Permit Z 0 3 (� $ 152 x 4� � 0 0 1 Z Tj� /it W 00 Gf SR� 0 $. $4t+ 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 -3420 F 209 464-0138 1 www . sjcehd Com EHD 29-01 04-04-07 Site Mitigation Well Permit Application