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SAN JOAQUIN Erindr nmentao c-Iep 'ffi Depc-arilmwam COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CAT (209) 953-7697 For INSPECTIONS C Apaw_ ?'RO 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 1904 West Charter Way City/State/Zip Stockton/CA/95206 Phone (925) 278-8688 Cross Street Tillie Lewis Drive APN 163-020-41 Property Owner* Glenn Springs Holdings, Inc. Phone (713) 552-8765 Address 5 Greenway Plaza, Suite 110 City/State/Zip Houston/TX/77046 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone (707) 639-7709 Address 6821 8th Street City/State/Zip Rio Linda/CA/95673 Consultant/Sub-Contractor Geosyntec Consultants, Inc. License# Phone (925) 278-8688 Address 1340 Treat Boulevard, Suite 208 City/State/Zip Walnut Creek/CA/94597 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5.5 feet ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 4 I nCh ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER M SOIL BORING 5 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ® HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs S-1 , S-2, S-3, S-4 and S-5 GROUT SPECIFICATIONS Neat Cement 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: Five shallow soil bgrings will each be a.0vance�to 5.5 feet below round surface to collect soil samples at each of the borina locations. as descvrl ed In t e attached Work Flan. 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed ( 2� Title/Company Senior Scientist/Geosyntec Consultants, Inc. Print Name Ronald M. Gestler Date August 15, 2024 f DEPARTMENT USE ONLY Application Accepted By: ----�� "''� Date Issued: � � 162 Grout Inspection By/Dates: ` Destruction Inspection By/Dates: s �� PC 2 p`� Facilit /Site Information FA Name e( 46j>l FA Address t' FA# '' q PR# d FA PE rx t WP Reviewed By Work Plan Date 1 ("l / Q ❑C-57 4C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement ' Lead Agency Approval I,MFR COMMENTS/CONDITIONS: ub re to jvu i' 1 esu' (l J>e �Secl Wkk& �_�� b� 1e. d wit der_. j. tV r-�r& L7A� k,� ant.z r A L41 . WP TYPE PPE SC FEE INFO AMT RELMIITTED CHECK# RECV'D BY DATE ( � WELL PERMIT# INVOICE# Permit . 1� �`3 $1 ,X ��Z �. 3 r `T i� f�`� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application