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SAN JOAQUIN COUNTY Greatness grows he, e. 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) 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 540 East Main Street Cross Street South American Street City/StatelZip Stockton, CA 95202 APN 149-150-'"20 Property Owner* San Joaquin Real Estate Company, Inc. TA II I Acquisitions, LLC -Potential Purchaser Address 3000 Olympic Blvd, Suite 2120 City/State/Zip Santa Monica, CA 90404 C-57 Contractor Trinity Drilling, Inc. License# 1010926 Address 114 Fern Street Consultant/Sub-Contractor ATON, LLC Glenn Scherer Address 2275 Cassens Drive, Suite 118 City/State/Zip Santa CruzCA 95060 , License# City/State/Zip Fenton, MO 63026 Phone Lorene Boudreau -Legal Counsel for Phone RP 4215) 864-8245 Phone 831.426.5607 Phone 636-349-0202 x 102 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ft and up to 25 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE 2 temporary[] MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER {� SOIL BORING 1 temp GW V PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: Casing Depth: ElINJECTION (Air Sparge, Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ❑ HOSE (PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes S/No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs SB -1, $661awilmid" GROUT SPECIFICATIONS Each bore hole will be grouted from the bottom up using Portland cement grout and if the bore hole is 30 feet deep or greater a tremie pipe will be used. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED See work elan ❑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: 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 Print Name David A. Reinsma Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: FacilitvlSite Information Cesar Ruvalcaba Title/Company President, Trinity Drilling, Inc. Date 10.14.2021 DEPARTMENT USE ONLY Issued: 10/ 18/2021 FA Name CONFIRMATION NUMBER 133253017 SR0084362 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 Commercial Property FA Address 540 Main FA# FA0026827 PR# PR0547252 FA PE 2950 WP Reviewed By Cesar Ruvalcaba Work Plan Date 10/12/2021 D4 C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval MFR COMMENTS/CONDITIONS: Submit copy of the results per SJC well standards section 13.7.2 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2905 13 13 1$152 x 2425 342 cc JW 10/15/21 WP0042674 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application