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SAN P JOAQUIN Environmental Health Department I — - - COUNTY - - - 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 8095 N Rio Blanco Road City/State/Zip Stockton ICA / 95219 Phone 209-952-1000 Cross Street W 8 Mile Road APN 06605052 Property Owner* Howard Weinberg Phone 310-363-7775 Address 2550 Via Tejon , suite 2B City/State/Zip Palos Verdes / CA / 90274 C-57 Contractor Cascade Drilling, LP License# 1058336 Phone 925-849-6970 Address 3451 Collins Avenue City/State/Zip Richmond / CA / 94806 Consultant/Sub -Contractor PES Environmental Inc . License# Phone 415-899-1600 Address 7665 Redwood Blvd. Suite 200 City/State/Zip Novato / CA / 94945 CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS it Z ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 1 - eet — BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE 2 .25-inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS i4nch inside diameterrYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER ® SOIL BORING 6 ® PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia : Casing Dia: Casing Depth: ❑ INJECTION (AirSoarge. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH To surface TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE '§j OTHER / —�� I OTHER: GROUT SEAL PUMPED? ElYes ® No (Note: Maximum Freefall Depth is 30 Ft) (VELLI SOIL BO ID , } GROUT SPECIFICATIONS Freefall , unless GW encountered in which case tremie pipe will be used . Neat Cement, DESTRUCTION WORK TO BE PERFORMED . DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑ 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 : 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 L041 Title/Company Staff Gelogist / PES Environmental, Inc. Print Name Lauryl Rudolph Date 2-5-2020 DEPARTMENT USE ONLY Application Accepted By: Aaron Gooderham Date Issue(i * 2 / 17/2021 Grout Inspection By/Dates : A I ta ;2 ^ / CIO Destruction Inspection By/Dat Facilit /Site Information J FA Name Paradise Point Marina FA Address 8095 Rio Blanco Road FA# FA0023127 PR# Sri FA PE WP Reviewed By AG Work Plan Date 9/3/2020 Z3Z ❑ C-57C 57 Authorization for Other to Sign Permit *Oor�kers Comp [IWorker's Comp Waiver ElEncroachment Permit IAccess Agreement ead Agency Approva MFR COMM ENTS/CONDITIONS : #; " p � � a k� �l � � 3 G� 4�(J 6 ' d 3IV n X f '� 6 �lCUE WP TYPE PE S / FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit 2905 3 .13 $ 152 x 3 $ 456 . 00 Card AG 2 / 12 /2021 WP0041711 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468 -3420 1 F 209464 -0138 www . Sicehd . com EHD29 -0108-01 -17 Confirmation Number : 120301967 Site Mitigation Well Perm it Applicatign 1 � �'Ir