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1"` SANJOAQUIN , Environmental Health Department —COUNTY " r 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 µ6 g - 033s— 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 2085 E. Main Street cityistate/zip Stockton, CA 95205 Phone Cross Street C Street APN 153-102-100-000 Property owner' BP Products North America, Inc. Phone 360-594-7978 Address 4 CenterpointeeDDririve Suite 200 citylstatewip La Palma, CAA 99/0623 � / C-57 Contractor 93g7'IU Liceg0.se# 1�a�©{9'r05(05D /2 �9 Phone p1R-63R-11G9 Address 3000 DULUTH ST a rtJ� Moot pt�ty/�fate Zip IRACR MENTO, 95691 V7 Consultant/Sub-Contractor p Antea Group USA, Inc. License# 548062 Phone 562-221-2503 Address 11010 White Rock Road, Suite 140 city/state/zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offshe Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS tO MONITORING 3 ® HOLLOW STEM BORING DEPTH 50 It t$BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporM7afer) ❑ HAMMERDRIVEN DIA.OF BOREHOLE 8in ❑MULTIPLE CASINGS❑MULTI-LEVELWELLCASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS 21nch diia.a. TYPE OF CASING: ❑STEEL IN PVC ❑ OTHER M SOILSORING 1 [I PUSH POINT(GPTCPT) CONDUCTORCASING ❑Yes l'.t]No Boring ON: Casing Dia: Casing Depth: ❑ INJECTION fAIrSoaae omnel ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: El AUGERS ❑HOSE IN PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Ea Yes [3 No (Note:Maximum Freefall Depth is 30 Ft) WELUSOILBORINGIDs —MVV--T,-MW-2, MW-4, SBA GROUT SPECIFICATIONS M 't swwb chip transition seal, Portland cement wA"p±-:-- 0q 11,66Ye �YLRVt DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD, (CHECK ALL THAT APPLY) Or tlSe y-Fr/c� #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETERof_inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to_feel below surface TREMIE TYPE TO BE USED El AUGERS ❑HOSE El 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 u_in County Ordinance Codes and Standards, and all other applicable California laws:- Signed Title/Company Project Manager /Antea Group Print Name Many Padilla Date 11/18/2019 DEPARTMENT USE ONLY Application Accepted By: Dale Issued: �/ I j / ^Q 19 Grout Inspection By/Dates' Destruction Inspection By/Dates: Facili /Site Information FA jNal / (f, FAAddress U' 1 FA# OD ZSez5PR#FA 2 g WP Reviewed By /; Work Plan Date 57Authorization for Other to Sign Permit ❑Workeescump ❑Workers Comp Waiver ❑Encroachment Pand ❑AccssAgraemenl ❑Lead Agency Approval ❑MFR COMMENTS/C NDITIONS:(NI tA�I �yQ IV ��A �JwLys t�,�, Rj OK J ytq 3gp1/r �/�q 1 r:s o�artur: r7 D "-_Jl� ��►�<r cf, J J l WP TYPE PE SC - FEE INFO AMT REMPITED1 CHECK# I RECV'D BY I DATE I WELL PnnERMIT# INVOICE# —d Permit 13$152 X q I C . 1868 E, Hazelton Avenue l Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.Sjcehd.com EHD 29-010a-01-17 Site Mitigation Wed Permh Appliravon 5P 05)5oq