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t SAN JOAWN " l COUNTY Grentness grows here. Environmental Health Department 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 street in front of 640 N. San Joaquin St. city/state/zip Stockton, CA 95202 Phone Cross Street Park St. APN Property Owner* City of Stockton (ROW) Phone Address 345 N. EI Dorado St. City/State/Zip Stockton, CA 95202 C-57 Contractor Gregg Drillinq LLC License# 1044456 Phone 925-313-5800 Address 950 Howe Rd. ConsultantlSub-Contractor ATC Group ServlCes LLC Address 1117 Lone Palm Ave. Ste. 201 B License# Phone City/State/Zip Martinez, CA 94553 City/StatelZip Modesto, CA 95351 209-579-2221 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Boringsr'Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 2 ® HOLLOW STEM BORING DEPTH 65 ft. ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA, OF BOREHOLE 8 in, ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS sCft �U' TYPE OF CASING: ❑ STEEL M PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone l ❑ HAND AUGER GROUT SEAL DEPTH 55 ft, 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 MW11 & MW12 GROUT SPECIFICATIONS neat Cement DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS 171 HOSE ❑PIPE COMMENTS: Signed Print N Application Accepted By: Grout Inspection By/Dates: DESTRUCTION am authorized to complete this application and that the work will be done in accordance with San Joaquin METHOD: and Standards, and all other applicable California laws. (CHECK ALL THAT APPLY) ❑ 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 feet below surface or feet below surface if >3 feet El 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. Destruction Inspection By/Dates: -a�nuyronc uiiviruauvn L � FA Name FA PE WP Reviewed By Title/Company Project Manager, Gregg Drilling, LLC Date 2/17/2021 Date Issued: .-J Work Plan Date ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: �� / )�h, L� �.� �� C �—�p,�A, �'� . �—* Z O�'q,L ✓t C�-�V._0004�ro eL CLS t WP TYPE PE SC FEE INFO JAMT REMITTED CHECK# RECV'D PYJ DATE WELL PERMIT# INVOICE# Permit eio 3 $152 x .fes f 5L z/f 9 i wFoo q 1 gzj 1868 E. Hazelton Avenue � Sto(, )n, California 95205 � T 209 468-3420 � F 209 464-0138 1 www.sjcehd.com EHD 29-01 OS -0 1-17 Site Mitigation Well Permit Application