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o�au'"•.c SAN JOAQUIN COUNTY ENARONMENTAL HEALTH DEPARTMENT = 1868 HaELlton AEenue, Stockton, CA 95205-6232 •. ' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.smcehd.com LixpR SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REF-INDABLE PERMIT E_PIRES 1 YEAR FROM DATE ISS-IED Application is hereby made to San Joa uin County for a permit to construct and/or install the cork described. This application is made in compliance kith San Joaquin County De-elopment Title,Chapter 9-1115.3,and the San Joa-uin County-i ell Standards. Job Address 2546 French Camp Turnpike City/State/Zip Stockton,CA 95206 Phone Cross Street Buena Vida Court APN 165-261-260-000 Property Owner* Lance Davidson Phone 505-301-6339 Address 6209 Cumberland Place City/State/Zip Stockton, CA 95219 C-57 Contractor GeoEx Subsurface License# 954267 Phone 916-799-8198 Address 1510 Madera Drive City/State/Zip Dixon, CA 95620 Consultant/Sub-Contractor Fulcrum Resources Environmental License# Phone 916-479-0859 Address 415 W.Chestnut Avenue City/State/Zip Monrovia,CA 91016 CONSTRUCTION WORK TO BE PERFORMED: :Note-i Offsite Borings/-i ells ReDulre Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 25 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) © HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA • SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ® OTHER None ® SOIL BORING 3 I41 PUSH POINT(GP/CPT)* CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaroe.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 SB-1,SB-2,SB-3 GROUT SPECIFICATIONS GROUT MUST BE TREMMIED IF WATER IS ENCOUNTERED; 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 [IHOSE [IPIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: "PUSH POINT ACCORDING TO WORK PLAN Total of three boreholes-borings will be advanced for soil and groundwater collection,then backfilled to set temporary shallow soil vapor probes. I 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 — Title/Company Staff Geologist,Fulcrum Resources Print Name Forest Kan Date 7-12-21 DEPARTMENT USE ONLY Application Accepted BYL JEFFREY WONG Date Issued❑ 7/27/2021 Grout Inspection By/Dates❑ JEFFREY W-NG_ 81/6/7071 Destruction Inspection By/Dates❑ Facility/Site Information FA Name 2546 French Camp Phase II FA Address 2546 French Camp FA# FA0026694 PR# PR0547076 FA PE 2950 WP Reviewed By JW Work Plan Date 7/6/2021 ❑C-57 ®C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ZI MFR COMMENTS/CONDITIONS: Submit a copy of the report/sampling results to EHD per SJC Well Standards 13.7.2 SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit 2905 1 313 3 HR 456 CC I JW 7/27/2021 WP0042347 BOA debit Card 866-255-1857 SR0084002 EHD 29-01 10-26-2015 Site Mitigation L ell Permit Application