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I <br /> �° M= SANJOAQUIN Environmental Health Department <br /> t t <br /> (.� OUNTY <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 501 S. Ventura Ave City/State/Zip Stockton , CA 95203 Phone 510.846.4438 <br /> Cross Street W. HazeltonAve APN 145-080-02 <br /> Property Owner* Daniel Munzer/Munco, Inc. Phone 562-283-1014 <br /> Address 3450 E Spring St, Suite 218 City/State/Zip Long Beach , CA 90806 <br /> C -57 Contractor Gregg Drilling License# 1044456 Phone 925.768 .8693 <br /> Address 950 Howe Rd City/State/Zip Oakland , CA 94612 <br /> Consultant/Sub =Contractor Jacobs License# N/A 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 TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER <br /> N SOIL BORING 16 ❑ 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 3K, 4K (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 /> Grout Inspection By/ Dates : 10)4 <br /> Destruction Inspection By/Dat <br /> Facilit /Site Information <br /> FA Name KOPPEL STATION TERMINAL FA Address 2 25 W . HAZELTON FA# FA0007013 PR# PRO505804 <br /> FA PE 2960 WP Reviewed By JW I Work Plan Date 5/4/2021 <br /> ❑ C-57 [ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement RI Lead Agency Approval ® MFR <br /> COMMENTS/CONDITIONS : <br /> 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# I RECV' D BY I DATE WELL PERMIT# INVOICE# <br /> Permit 2905 13 1 $ 152 x 3 56 CC JW /219/2021 WP0042317 <br /> Confirmation number 128635201 SR0083983 <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468- 3420 F 209 464 -0138 1 www . sjgov . org /ehd <br /> EHD 29-01 06-28-21 Site Mitigation Well Permit Application <br />