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SAN JOAQUIN <br />1, i' C O U N Y <br />:c <br />Greatness grows here. <br />Environmental Health Department <br />SITE MITIGATION WELL Ot BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 953-7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address COS ROW to 1602 Turnpike Road and 1425 S Center Street City/StatelZip Stockton, CA 95206 Phone <br />Cross Street Lincoln Street and Turnpike Road <br />Property Owner* City of Stockton <br />Address 425 North EI Dorado Street <br />C-57 Contractor AdvancedGeo, Inc. <br />Address 837 Shaw Road <br />Consultant/Sub-Contractor c e99 ^ is =�— ConeTec <br />950 Howe Road <br />City/Statelzip Stockton, CA 95202 <br />License# 680 <br />227 <br />City/State/Zip Stockton, CA 95215 <br />License# 1044456 1049248 <br />Phone <br />(209) 937-8444 <br />(209)937-8444 <br />Phone (2os)as7-loos <br />510 357-3 <br />94577b77 <br />Adores 820 Aladdin City/state/zip San Leandro, CA <br />Revised per <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits Evan Schmidt <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 10/7/2021 <br />El MONITORING ❑ HOLLOW STEM BORING DEPTH 70-120 feet E] BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />El EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2 inches El MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />El SOIL VAPOR PROBE El MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL [I PVC El OTHER <br />El SOIL BORING 6 10 PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes ®No Boring Dia: Casing Dia: Casing Depth: <br />El INJECTION (Air Sparge, Ozone) El HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS [I HOSE [I PIPE <br />El OTHER El OTHER: GROUT SEAL PUMPED? El Yes ®No (Note: Maximum Freefall Depth is 30 Ft) must be tremmied if <br />WELL/ SOIL BORING IDs CPT -2A, CPT -2B, CPT -2C GROUT SPECIFICATIONS PORTLAND TYPE II CEMENT TO SURGACE GRADEMOM =�11111111316rs <br />CPT -3A, CPT -3B, CPT -3C <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED EJ AUGERS ❑HOSE [:1 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />❑ MUSHROOM CAP El feet below surface or feet below surface if >3 feet <br />COMMENTS: CPT -2A and CPT -3A will be drilled to 120 feet bsg for litologic classification. CPT -26 and CPT -3B will be drilled to 75 feet bsg for grab groundwater sampling. CPT -2C and CPT -3C will <br />be drilled to 120 feet bsg for grab groundwater sampling. Borings within a few feet of eachother, <br />hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print Name Evan scnmidt <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/[ <br />Facility/Site Information <br />JEFFREY WO <br />Title/Company Staff Geologist, AdvancedGeo, Inc. <br />Date September 3rd, 2021 <br />DEPARTMENT USE ONLY <br />Date Issued: 9/.16/2021. <br />FA Name <br />LOPEZ PROPERTY <br />FA Address <br />1601 TURNPIKE <br />FA# <br />FA0023498 <br />PR# <br />PR0541037 <br />FA PE <br />2960 <br />WP Reviewed By <br />1W <br />Work Plan Date <br />4/14/2021 <br />hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print Name Evan scnmidt <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/[ <br />Facility/Site Information <br />JEFFREY WO <br />Title/Company Staff Geologist, AdvancedGeo, Inc. <br />Date September 3rd, 2021 <br />DEPARTMENT USE ONLY <br />Date Issued: 9/.16/2021. <br />FA Name <br />LOPEZ PROPERTY <br />FA Address <br />1601 TURNPIKE <br />FA# <br />FA0023498 <br />PR# <br />PR0541037 <br />FA PE <br />2960 <br />WP Reviewed By <br />1W <br />Work Plan Date <br />4/14/2021 <br />14 C-57 [IC -57 Authorization for Other to Sign Permit <br />❑ Worker's Comp El Worker's Comp Waiver Ij Encroachment Permit El <br />Access Agreement Lead Agency Approval MFR <br />COMMENTS/CONDITIONS: <br />Submit a copy of the report/results to EHD per SJC Well Standards 12.7.3 <br />- COS encroachment permit EP21-1713 on file -CPT subcontracted to Gregg but under AGE's C-57 license <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />2905 <br />1313 <br />$152 x 3 <br />456 <br />CC <br />JW <br />9/14/2021 <br />WP0042551 <br />confirmation number; 131227178 SR0084223 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 vvww.sjgov.org/ehd <br />EHD 29-01 06-28-21 Site Mitigation Well Permit Application <br />