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SAN JOAQUIN COUNTY Grea>~ness brows here, 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 2500 Navy[ Drive City/State/Zip Stockton CA 95206 Cross Street Ort J. Lofthus Fwy Property Owner* Art O'Brian /City of Stockton, Municipal Utilities Department Address 2500 Navy Drive C-57 Contractor Tom Scott /Geo -Ex Subsurface Exploration Address 1510 Madera Drive COnSUltant/SUb-Contractor Kleinfelder, Inc. Address 2001 Arch Airport Road Suite 100 Ap N 163-330-030-000 City/State/Zip Stockton CA 95206 License# 954267 City/State/Zip Dixon CA 95620 License# 467252 City/State/Zip Stockton CA 95206 Phone 209.937.8460 Phone 209.937.8460 Phone 916.799.8198 Phone 209.327.0998 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ❑ MONITORING ❑ ❑ EXTRACTION (VapodWater) ❑ ❑ SOIL VAPOR PROBE ❑ ❑ SOIL BORING ❑ ❑ INJECTION (Air sparge, Ozone) ❑ ❑ OTHER ❑ WELL) SOIL BORING IDs INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA. OF BOREHOLE ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS 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 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ®OVER -BORE DIAMETER of � inches to depth of 5o feet WELL IDs MW -1 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS 3 gal. of water / 47 -Ib bag Portland Cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED n AUGERS n HOSE 171 PIPE n MUSHROOM CAP I—I 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 Staff Engineer/ Kleinfelder Print Name Application Accepted By: Grout Inspection By/Date Destruction Inspection By Date October 4, 2021 DEPARTMENT USE ONLY JEFFREY tiVONG Date Issued: 10/8/2021 Facility/Site Information FA Name City of Stockton Municipal Utilities FAAdtlress 2500 NAVY FA# FA0026333 PR# pR054656 FA PE 2965 WP Reviewed By JtiV Work Plan Date 10�4�2021 ❑ C-57 � C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement �1 Lead Agency Approval L� MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2902 � 13 $152 x 1 152 cc JW 10/5/2021 WP0042632 Confirmation # 132700377 SR0084325 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � vvww.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application