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° SAN� p ? GZ� ..JOAQUIN Environmental Health Department_. C O U N T Y—._..-- C, Greatness .rows her,. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 1000 W Benjamin Holt Drive City/State/Zip Stocton,CA 95207 Phone Cross Street Between Gettysburg Place and Pacific Ave APN 09741073 Property Owner* Phil Johnson Phone 209-478-9200 Address 374 Lincoln Center City/State/Zip Stockton,CA 95207 C-57 Contractor Gregg Drilling,LLC License# 1044456 Phone 707-239-2194 Address 2100GoodyearRd City/State/Zip Benicia,CA94510 Cons ultant/Sub-ContractorGeosyntec Consultants.Inc License# NSA Phone 530-771-7497 Address 3043 Gold Canal Drive,Suite 100 City/State/Zip Rancho Cordova,CA 95670 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH s0 n ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 0 SOIL BORING 7 0 PUSH POINT(GP CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: Casing Dia: Casing Depth: I-] INJECTION(Air Sparse.Ozone) [:1 HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 0 Yes ❑No (Note:Maximum Freefall Dep is 30 Ft) WELL/ BORING IDs CPT-1 and HP-1 through HP-6 GROUT SPECIFICATIONS Type II-V ��,r y,7r DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDS ❑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 feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �a quin County Ordinance Codes and Standards,and all other applicable California laws. Signed - Title/Company Senior Geologist/GeosyntecConsultants Print Name Jamie Purcell Date 4/17/25 _ DEPARTMENT USE ONLY l Application Accepted By: T �� Date Issued: 4k l rG C Z Grout Inspection By/Dates: 6 -4 2425 ST Destruction Inspection By/Dates: Facili /Site Information FA Name v 10��✓�� FA Address >� �� L A# pc. PR# FA PE 2�'� �,,Q WP Reviewed By Work Plan Date -57 -57 Authorization for Other to Sign Permit orker's Comp ❑Work is Comp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency Approval KFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Z�d5 3L'S P,1500670 $172x �� job' L �� &A��`� W 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 L p�j hibP�t Z Site Mitigation Well Permit Application