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SAN 10A0UIN for mental Health D -jpla Imam SITE MITIGATION WMLL & BORING PERMIT APPLICATION 24 Hours Adva] ye Notice Require_. r-�. I CALL (209) 953-7697 For INISPECTIONS 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 6471 Pacific Avenue (work near 236 Lincoln Center} IT tawr4ap Stockton, CA 95207 Cross Street Benjamin Holt Drive APN 097-410-79 Property Owner* Lincoln Properties Limited Address _ 374 Lincoln Canter City/StatelZip Stockton, CA 95207 G-57 Contractor PeneCore Drilling License#t 906899 Address 220 N. East Street City/StatelZip GVoodland CA 95776 ConsuttantJSutz-Corrtractor Geosyntec Consultants, lnc Address 3043 Gold Canal Drive, Suite 100 License# City/StatelZip Rancho Cordova, CA 95670 Phone 9't6-637-8325 Phone 209-478-9200 Phone 530-681-3600 Phone 916-637-8048 CONSTRUCTION WQRK Ttl BE RERFORMED: *Note: Offsite 8oringslWelfs Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING UMBER INSTALLATION TYPE Ct3NSTRUCTfDN SPEC IFICATIONS ❑ dAONITORItJG U 1 HOLLOW STEM BORING DEPTH 2 fEet, rte.10 BOLTED TRAFFIC BOX ❑ STOVE PIPE 0 EXTRACTION (Vapor/Water) 2 © HAMMERIORIVEN DIA, OF BOREHOLE 12 in ❑ MULTIPLE CASINGS I] MULTI-LEVEL WELL CASING DIA 0 SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑x PVC © OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING Q Yes ID No Boring Dda ❑ Casing plea — "��" �� INJECT}ON (Pir scarce OLMeI ❑ HAND AUGER GROUT SEAL DEPTH 3 and 7 feet, resp. TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ® PIPE g ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 19 Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs x-10 GROt rr SPSCIFICATIOf!S.Grout to t f�otrt bgs rq agow j,r KNd }max; n DESTRUCTI ON WORK TO BE PERF=t?RMED: DESTRUCTION METHOD' (CHECK ALL THAT APPLYI / .' � , �v # WELLS TO BE DESTROYED N/A Q OVER -BORE DIAMETER of inches to depth of feet WELL IDs El 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 fest below surface if>3 COMMENTS: Signed Print N� certify that f am authorized to complete this application and that the work will be done in accordance with anLnoaquin County Ordinance Codes and Standards, and all outer applicable Galifornfa taws. Title/Company Professional; Geos ntec Consultants Inc dodges Date August 26, 2021JA Of DE ARTMENT USE ONLY a Application Accepted By: Date Issued: 2 u Grout Inspection By/Dates: a ' .l Destruction Inspection By/Dates: t f=acillt !Site Information FA Name .n Cp n r VIdIYpA FA Address ' a f1'i/11!Eo FA# p p PR# d }t FA PE 2 9 6 d WP Reviewed By �w Work Pian Date T� 6 �2 Cl C-57 G57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement Lead Agency Approval R COMMENTSlCONDITIONS: S ,� dm pop a f� red cr-�j titV 04 WP TYPE PE SC FEE INFO AMT REMITTED /CHECK# RECV'D BY DATE , , 1WELL PERMIT# p INYOiCE# Permit 2q0 313 $152 x 3, 3d 868 E. Hazelton Avenue I Stockton, California 9520�r 1 1" 209 488-3420 1 F 209 64-018 1 wwvv.sj9ov.org/ehd EHL) 29-01 06-28-21 Site Mitigation Weil Permit Application