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SAN JOAQUIN G116J'O�li �l�Clu �� G`� �a :� �IIC;O�irr'a �i�Ci — -COUN 1 Y-- - 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 INSPECiIONS67�') ; / Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. ��( Z3 This application is made in C^rnnII� nra Ga^ Inn^ ;^ ' ^"^'" ^ ' ^'---lent Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job AddressCity Right-Of-Way West Jefferson Street,South Lincoln Street,Harrison Street City/State/Zip Stockton/CA/95206 Phone 800-511-9300 'V r Q Cross Street Clay Street and South Lincoln Street APN NIA 6-,- Property Owner` City Stockton Phone 209-937-8212 Address 425 North El Dorado Street City/State/Zip Stockton/CA/95202 C-57 Contractor AdvancedGeo Inc. License# 680227 Phone 800-511-9300 Address 837 Shaw Road City/State/Zip Stockton, CA 95215 Consultant/Sub-Contractor Gregg Drilling License# 1044456 Phone 925-313.5800 Address 950 Howe Road City/State/Zip Martinez/CA/94553 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 120, ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2' ❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA NIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NIA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER NIA 0 SOIL BORING 8 ❑x PUSH POINT(GP/CPT) CONDUCTOR CASING ❑ Yes El No Boring Dia: Casing Dia: Casing Depth: NIA ❑ INJECTION IA:Sparao,ozone) ❑ HAND AUGER GROUT SEAL DEPTH 120' TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE I]PIPE If OTHER ❑ OTHER GROUT SEAL PUMPED? ❑ Yes 0 No (Note:Maximum Freefall Depth Is 30 FQ t T r2� WELL/SOIL BORING IDs CPT.4 CPT-5 CPT 6.CPT.7,CPT-8,CPT-9, GROUT SPECIFICATIONS PORTLAND TYPE II CPT-10.CPT-II 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 San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed �� ,,,n� /�1,-^„/ Title/Company Staff Scientist/AdvancedGeo Inc. Print Name Maxwell Niemeyer Date 01/19/2023 DEPARTMENT USE ONLY Application Accepted By: pp ` lk' D e Issued: =3 7U Grout Inspection By/Dates:; s ' L -t Destruction Inspection By/Dates: ' Facilit /Site Information FA Name J I p ('s �f FA Address c FA# O O PP # FA PE t WP Reviewed By i j Work P n Date C' // `J" ��i ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit d Agency Approval ❑MFR COMMENTS/CONDITIONS: 61 r -I— J � Qc✓C WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D B D TE WELL PE MIT# INVOICE# Permit i -� $3a�X C VV"/ - LAC {f S�tbCJ C coV' (/ V L' ✓� '1868 E. Hazelton AvenLle Stockton, California 95205 209 468-3420 1 F 209 464-0138 1 www.sjcehd.CO EHD 29-01 04-04-07 �� ZZo "3 1 ) ,__ Site Mitigation well Permit Application