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AN JUAQUIN �reatness grows here. Environmental Health Department 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 145 South Sutter Street City/State/Zip Stockton CA 95202 phone (209) 468-1000 Cross Street East Washington Street APN 149-12-016 Property Owner* San Joaquin County General Services Department — Capital Projects Administration Phone 2091 Address 44 North San Joaquin Street, Suite 590 City/State/Zip Stockton, CA 95202 C=57 Contractor Cascade Remediation License# 1069034 Phone Address 3459 Collins Ave City/state/Zip Richmond, CA, 94806 Consultant/Sub-Contractor Weston Solutions, Inc License# A HAZ 522739 Phone Address 2300 Clayton Ave., Suite 900 City/State/Zip Concord, CA 94520 953-7046 510-772-0841 925-948-2655 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 43 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 24ch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING IX PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia; Casing Dia: Casing Depth: N INJECTION (Air sparge. Ozone) 10 El HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE X PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall De th is 30 Ft) WELL/ SOIL BORING IDs I P-01 to IP -10 GROUT SPECIFICATIONS N eCA+ C : � �'e—�.-K 'I DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED El AUGERS [:1 HOSE El PIPE (COMMENTS. Signed Print Name DESTRUCTION METHOD: (CHECK ALL THAT APPLYI ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet Injection of remedial amendments using direct push drilling to treat petroleum contaminants hereby certify that 1 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. U Manager - Cascade Title/Company g Chris Tatum Application Accepted By: Grout Inspection By/Dates. Destruction Inspection By/Dates: Facilitv/Site Information C Date 7/8/22 Date Issued: FA Name 0 Jr 1868 E. Hazelton Avenue 044� FA PE Zq 4 0 WP Reviewed By VU, Work Plan Date k� Zo ZI �C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval *M1 R COMIMENTS/CONDITIONS: L r-{— � �o rL 5 m�n,S� `6e,�1pf -�d S� C �{-� �2r ST WP TYPE PE SC FEE INFO AMT RE yITTEn CHECK# #ill a RECV'D BY DATE WELL PERMIT#p INVOICE# Permit �0,� �3 �_ d66 QOa a� O® �t.3'' WP �yStockton, California 9 2 �� T EHD 29-01 08-01-17 �� 209 468-3420 � F 209 -013 � vw�vw.sjcehd.com 4� y � � L -'_� ate�it�ati� Wel Permi��i�tior� ��O `1� 15 re $A WC4 ' � �C