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SAN JOAOUIN <br />—CoUNTv <br />Greatness grovvs here. <br />Environmental Health Department <br />SITE MITIGATION WELL &BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 953-7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 5110 E Mariposa Road <br />Cross Street None -near Clark Drive <br />Property Ownet'* Donald R. Lawley <br />Address 5110 E Mariposa Road <br />C-57 Contractor Neil O Anderson &Associates Inc. <br />Address 10841 S. Ridgeview Road <br />Consultant/Sub-Contractor <br />Terracon Consultants, Inc. <br />Address 902 Industrial Way <br />City/State/Zip Stockton, CA 95215 <br />APN 179-220-19 <br />17T.iT� <br />Phone <br />City/State/Zip Stockton, CA 95215 <br />License# 669004 Phone 913-599-6886 <br />City <br />License# Phone 209-367-3701 <br />City/State/Zip Lodi, CA 95240 <br />lStatelZip Olathe, KS 66061 <br />CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OFWELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING <br />❑ EXTRACTION (Vapor/Water) ❑ <br />ElSOILVAPORPROBE ❑ <br />® SOIL BORING 5 11 <br />lINJECTION (Air Sparge, Ozone l 1:1 <br />E] 171WELL/ SOIL BORING IDs <br />HOLLOW STEM BORING DEPTH 15 to 70 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMER/DRIVEN DIA.OFBOREHOLE 6 inch ❑ MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL El PVC El OTHER <br />PUSH POINT (GP/ CPT) CONDUCTORCASING ❑ Yes El No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS El HOSE El PIPE <br />OTHER: GROUT SEAL PUMPED? El Yes El No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE El PIPE <br />COMMENTS: <br />Signed <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP El feet below surface or feet below surface if >3 feet <br />1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />40�4,, Title/Company Professional Geologist / Terracon Consultants, Inc. <br />U� <br />Print Name Tony Mikacich Date February 18, 2022 <br />DEPARTMENT USE ONLY <br />Application Accepted By: JEFFREY W O N G Date Issued: 3/ 11 /2022 <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: Z.. Z <br />Facility/Site Information Proposed Distribution Center 4522 and 4600 Marfarqoq 54755, <br />FA Name FA Address FA# PRI <br />FA PE 2950 WP Reviewed By J1 <br />l.Ul 1111 <br />/�/ <br />Work Plan Date <br />2/22/2022 <br />El &57 IX G57 Authorization <br />for Other to Sign Permit <br />❑ Worker's Comp El <br />Workers Comp Waiver El Encroachment Permit El <br />Access Agreement ❑ Lead Agency Approval IN MFR <br />COMMENTS/CONDITIONS: <br />Submit copy <br />of report/testing <br />results to EHD per SJC Well Standards <br />13.7.2 <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />2905 <br />313 <br />$152x 3 <br />456 <br />CC <br />JW <br />3/2/2022 <br />WP0043069 <br />I I IdIIUI I tt I J.7VJV r JV <br />JI\VVV`t.7/ V <br />1868 E. Hazelton Avenue � Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 vwvw.sjgov.org/ehd <br />EHD 29-01 06-28-21 Site Mitigation Well Permit Application <br />