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t I 4 e w G :. P 1:as ® SITE IVIITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUN�.DABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED %&4 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 See Attached Map 0G�o City/State/Zip Stockton, CA 95219 phone..... . JCIAA M Cross Street Rio Blanco APN APN 06605042 Property Owner Stockton Westlake Investments Address 10100 Trinity Parkway, 5th Floor City/Statep C-57 Contractor Penecore Drilling License# Address 220 N. East Street City/State/Zip Stockton, CA 95219 Woodland, CA 95776 Phone Phone 530-661-3600 Consultant/Sub-Contractor Geosyntee Consulting, InC License# Phone Address 3043 Gold Canal Dr., Ste. 100 City/State/Zi Rancho Cordova, CA 95670 916-241-6331 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 feet ❑BOLTED TRAFFIC BOK ❑STOVE PIPE ❑ EXTRACTION (VaporANater) ❑ HAMMERIDRIVEN DIA, OF BOREHOLEZ ham— ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS 2 InCheS_ TYPE OF CASING: ❑ STEEL (R PVC ❑ OTHER SOIL BORING—® PUSH POINT (GP; CPT) CONDUCTOR CASING ❑ Yes ❑ No Dia: Casing Dia: _ Casing the ❑ INJECTION (AirSoarge, ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE PE TO BE USED: ❑AUGERS ❑ HOS PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (o e: imum Freefall Depth is 30 Ft) WELL! SOIL 9ORING IDs S!S�9 GROUT SPECIFICATIONSl'�------ # 4NELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS_ TREMIE TYPE TO BE USED COMMENTS: Signed Print Name FORMED: AUGERS ❑HOSE ®PIPE DESTRUCTION METHOD: ICHECK 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 (-1 MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet certifiy 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 taws. � C. Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: -aclllty/Slte Intormatlon Title/Company LY Date Issued: FA Name � FA PE WP Reviewed By Work Plan Date Z� Z"I A 5�0 C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit Access Agreement F1 Lead Agency Approval MFR DOM TSICONDITIONS: j % r0 (/ Skws O Wu t S4) I 4�v- !2 WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D Y DATE WELL/IPERRMIT# INVOICE# Permit $1S`/ �� 0, ` vV �( T i 6U z , I cZ l L H / r,LiLStockton. �� ?i moi'? i J�z� G 1 a 209 .s.6s?., 32, 20 20tJ . , I v1 wh4.t Ci?"i EHD 29-01 08-01 -1 7 Site Mitigation Well Permit Application �S�