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Permit Application 4of4 SAN JOAQUIN Environmental Health Department 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 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 9-1116.3, and the San Joaquin County Well Standards. Job Address Pacific Avenue Frontage Road citylstatelzip Stockton. CA 95207 Phone Cross street Pacific Ave and W Benjamin Holt Dr APN Property Owner" City of Stockton Phone Address City/State/Zip C-57 Contractor PerTecore Drilling License# 906899 Phone 530-661-3600 Address 220 N East St City/StatelZip Woodland, CA 95776 Consultant/Sub-Contractor Geosyntec Consulting License# Phone Address 3043 Gold Canal Dr Suite 100 citylstatelzip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BoringsA(Vells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapUnWater) ❑ HAMMERDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes []No Boring Die: Casing Dia: Casing Depth: ❑ INJECTION rAirsoarae.ozmal Q HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freelall Depth is 30 Ft) WELU SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PER OR D: DESTRUCTION METHOD: (CHECK ALL THATAPPLYI i #WELLS TO BE DESTROQYED 24 dL G )• I fo Z Z t4 OVER-BORE DIAMETER of 8-10 inches to depth of�5 yfeel [, ,o WELL IDs Seekmch 'lj o S'� A%W Z ❑PRESSURE GROUT Todepthof feelbelowsurface /V C l &a4y t 6�( GROUT SPECIFICATIONS Neat cam�sgai water a 47roeg r a e ®EXPLOSIVES From to 85 feet below surface AK TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE PIPE El MUSHROOM CAP ❑ 6belowsurfamor feet below 5urfaceif>3 feet COMMENTS: f.1 rM 41 L(".TL dYA J r Gam► or L.` � ar 4 See list of attached wells and well information.All IDW will be hauled off by a hazardous waste certified company. st"�ace -tok I he y ertify that I am authorized to complete this application and that the work will be done in accordance with �� ; 1 r an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. '-CT Signed Title/Company Project Geologist - Ceosynlec Consultants L Print Name Jamie Purcell Date 9/14/23 V DEPART NT USE ONLY Application Accepted By: Date I sue ZO Grout Inspection By/Dates: i NFL J Destruction Inspection By/Dates: Facilit /Site Information FA Name 'D / r .�Y FA Address tG 6ft S At FA# 100 7 PR# Q r FA PE WP Reviewed By Work Plan Dale z 0G57 ❑C-57Authonzabonf"ONerto Sgn Permit ❑Workers Gemp ❑Wonels Comp Waver ❑Ercraachmenl Pe I ❑AoiessAgreemenl Agency Approval �i R COMMENTS/CONDITLT IT t (red n Ill ffm �j�eztc4� ►nw � r�Worr�lde J�4c� be�� Ialn�o w- WP TYPE I �/ PE '7 SIC? /'FEE INFFFO AMT RR�EMrr-rED CHHE/C�K# RECV'D BY DRAT CWELL PE1R/M�IT# INVOICE# Permit 2 �` 36 It'X ✓ ; 10 I .JV(� l L� W?00�l�+� 90��22�"' 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138� %WWs ace dRn EHD 2901 04-20-23 Site Mitigation Well Permit Application