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SAN JOAQiN COUNTY Greatness grows here. Environmenral 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 619 N. San Joaquin St. Cross Street Oak St. Property Owner* Service First of Northern California Address 102 W Bianchi Rd. C-57 Contractor Gregg Drilling LLC Address 950 Howe Rd, Consultant/Sub-Contractor ATC Group Services LLC Address 1117 Lone Palm Ave. Ste. 201 B City/State/Zip Stockton, CA 95202 Phone AP 139-060-150 •❑it.Tii� City/Statelzip Stockton, CA 95207-7132 License# 1044456 Phone 925-313-5800 city/Statelzip Martinez, CA 94553 License# City/Statelzip Modesto, CA 95351 Phone 209-579-2221 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ® MONITORING 1 IW ❑ EXTRACTION (Vapor/Water) El ❑ SOIL VAPOR PROBE El ❑ SOIL BORING ❑ ❑ INJECTION (Air Soarae.Ozone) ❑ El OTHER ❑ WELL/ SOIL BORING IDs MW13 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH 65 f t. ®BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA, OF BOREHOLE 8 jn, ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS sC 4U' TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH 55 ft. TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE ❑ PIPE OTHER: GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS neat rpment DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE F1 PIPE MMENTS: Signed DESTRUCTION METHOD: (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 ❑ 3 feet below surface or feet below surf ertify 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. Title/Company Project Manager, Gregg Drilling, LLC Print Name U Ryan Lea Date 2/17/2021 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Sita Infnrmatinn Date Issued: FA Name � �y ©-�� (� �� FA PE rl 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site FA Address WP Reviewed By ) FA# O O Z 3 Work Plan Date PR# � ElC-57❑ C-57 Authorization for Other to Sign Permit El Worker's Comp El Worker's Comp Waiver El Encroachment ace if >3 feet ertify 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. Title/Company Project Manager, Gregg Drilling, LLC Print Name U Ryan Lea Date 2/17/2021 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Sita Infnrmatinn Date Issued: FA Name � �y ©-�� (� �� FA PE rl 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site FA Address WP Reviewed By ) FA# O O Z 3 Work Plan Date PR# � ElC-57❑ C-57 Authorization for Other to Sign Permit El Worker's Comp El Worker's Comp Waiver El Encroachment Permit [:1 Access Agreement ❑ Lead Agency Approval El MFR COMMENTS/CONDITIONS:�er SJ � WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit q� $152 x S Z �Jlij� 2 W 1 Mitigation Well Permit Application