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S A N J O A Q U I N Environmental Health Department , —COUNTY— Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 925 North Wilson Way city/state/zip Stockton. CA 95205 Phone Cross Street East Acacia Street APN 151-050-450 Property owner* LKO Investments LLC Phone 209-948-1524 Address 925 North Wilson Way City/StatelZip Stockton, CA 95205 C-57 contractor Environmental Control Associates Inc (ECA�icense# Rg5g70 Phone Address 3011 Twin Palms Drive Cilylstatelzip AMOS, Ca Consultant/Sub-Contractor Partner Engineering and Science License# N/A Phone Address 1544 Eureka Road Suite 180 city/state/zip Roseville. Ca 95661 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsile Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH lbft ❑BOLTED TRAFFIC BOX [I STOVEPIPE ElEXTRACTION(Vapor7Waler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER Dj SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes El No noting Dia: Casing Dia: Casing Depth: ❑ INJECTION fAkaoame ezanl ❑ HANDAUGER GROUTSEALDEPTH THEME TYPE TO BE USED. ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [I Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WEWSOILBORINGIDs B throu.gh 135 GROUT SPECIFICATIONS Noat romant/t) nt(1nItP DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_inches to depth of feel WELL IDs ❑PRESSUREGROUT To depth of—feet belay surface GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑PIPE El MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet COMMENTS: Five soil borings to 15 feet bgs. Soil gas probes constructed in each at 5 feet bgs. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with _ Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed_--, Title/Company Title/Company Partner Engineering and Science Inc. Print Name Lauren Hinch, Staff Geologist Date 9/10/2090 E ARTMENT USE ONLY /^ r Application Accepted ey: Datd Iss ed: GJ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit (Site Information i FA Name r[/� FA Address ' ' FA# Bp I Z PR# li FA PE J WP Reviewed By Work Plan Date ❑C57 57 Aulhorizalbn for Olherto Sign Permit ❑Workers Co p ❑Workers Comp Walvef ❑Encroachment Pemtlt ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/ ONDITIONS: 5 ( AA4 -k6 i3.' • Z Tho-t- sp-usc# -h wl lc�� o w re�� F Hole sw�f +tt rule LG / e� eu►�aeM-f WP TYPE I PE sC FEE INFO AMT REMIT D CHECK# I RECV•D BY DATE Wr;LL PERM�IIT# INVOICE# Permit go$152x �' G rY W�66 � I `�3 1868 E. Hazelton AV nue I �(tockton Cal�'f{ornI'a J5205 IafT nn209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0106-01-17 � I AAAr �f (N / yyr&/.f / ita Mjtigal Wpl efm_(Wplication