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SAN JOAQUIN Environmental Health Department --COU NTY--- Greatness gror,s he; e. 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 COS ROW to 807 and 845 East Lindsay Street City/State/Zip Stockton, CA 95202 Phone (209)937-8444 Cross Street North Grant Street and North Aurora Street APN Property Owner* City of Stockton Phone (209)937-8444 Address 425 North El Dorado Street City/State/Zip Stockton,CA 95202 a CU 0 5 C-57 Contractor AdvancedGeo, Inc. Licen e# 680227 Phone (209)467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA 95215 ConsultantlSub-Contractor Gregg Dulling Ltce nse# 1044456 Phone (925)313-5800 Address 950 Howe Road City/State/Zip Martinez,CA 94553 ( >CN r'Z� CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH Maximum 90 feet ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 inches ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING 9 ® 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 ® N Note:Maximum Freefall Depth is 30�Ft)�'� ) WELL/SOIL BORING IDs CPT-10a,CPT-10b,CPT-10c,CPT-ila,CPT-11b, GROUT SPECIFICATIONS PORTLAND TYPE II CEM 7ADE �► �'� Lf'�� "C��M� CPT-11c CPT-12a CPT-12b CPT-12c,CPT-13a,CPT-13b,CPT-13c,CPT-13d DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) �TV ~ #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet i y) 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: CPTs will be drilled to a maximum of 90 feet bsg for litologic classification and grab groundwater sampling.Borings within a few feet of each other. 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 ra Title/Company Staff Scientist,AdvancedGeo, Inc. Print Name Kylie Kucera Date 12 June 2023 DEPARTMENT USE ONLY Application Accepted By: Lkj, Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information A _ FA Name Y ' ' ��'�� FA Address © FA# `��; PR# �j - FA PE ctWP Reviewed By Work Plan Date ❑C-57 ��57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver .encroachment Permit cess Agreement 'ead Agency Approval R F COMMENTS/C°ONDITIONS: C �� "Oe v.imf L -3 ,__I [f, e6* � �r I WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RE`CV'D�BY DATE 1 WELL PERMIT# INVOICE# Permit F .. $;0-<', " Y �� lb 1868 E. Hazelton /Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application