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SAN JOAQUIN Environmental Health Department <br /> iY44 <br /> ,°<: . . COUNTY <br /> �� rea7t ;� a4 grows here . <br /> SITE MITIGATION WELL & 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 2025 West Hazelton Ave City/State/Zip Stockton , CA95203 Phone 510.846.4438 <br /> Cross Street SVentureAve APN 145-030-06 <br /> Property Owner* George Weinberger Phone 209.639. 1211 <br /> Address 40 Belgrave Ave City/State/Zip San Francisco, CA 94117 <br /> C -57 Contractor Gregg Drilling License# 1044456 Phone 925.768.8693 <br /> Address 950 Howe Rd City/State/Zip Martinez, CA 94553 <br /> Consultant/Sub-Contractor Jacobs License# NA Phone 510.846.4438 <br /> Address 155 Grand Ave, Suite 800 City/State/Zip Oakland , CA 94612 <br /> CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6 ft bgs ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br /> ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 4-inch ❑ MULTIPLE CASINGS ❑ MULTI- LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER <br /> SOIL BORING 24 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth : <br /> ❑ INJECTION (Air sparge, Ozone) ❑■ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br /> WELL/ SOIL BORING IDs 2K, 5K, 6K (See Work Plan) GROUT SPECIFICATIONS Neat cement will be poured into the hole once soil samples have been collected. <br /> DESTRUCTION WORK TO BE PERFORMED . DESTRUCTION METHOD : (CHECK ALL THAT APPLY) <br /> # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br /> COMMENTS : <br /> I 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 Title/Company Project Manager/Jacobs <br /> Print Name Jenny Salinas Date 7/19/21 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By : JEFFREY WONG Date Issued : 7/21 /2021 <br /> r� <br /> Grout Inspection By/Dates : KA !i <br /> Destruction Inspection By/Dates : <br /> Facilit /Site Information <br /> FA Name Koppel Station Terminal FA Address 2025 W . Hazelton FA# FA0007013 PR# PR0505804 <br /> FA PE 2960 WP Reviewed By JW Work Plan Date 5/4/2021 <br /> ❑ C-57 M C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access AgreementX ❑ Lead Agency Approvax ❑ MFR <br /> COMMENTS/CONDITIONS : Submit a copy of the report/results to EHD per SJC Well Standards 13 . 7 . 2 <br /> WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# <br /> Permit 2905 13 $ 152 x 3 456 CC JW 7/20/2021 WP0042318 <br /> Confirmation number 128718197 SR0083983 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 1 F 209 464 - 0138 1 www . sjgov. org /ehd <br /> EHD 29-01 06-28-21 Site Mitigation Well Permit Application <br />