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SAN JOAQUIN Environmental Health Department COUNTY 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 1810 East Hazellon Avenue CilylSlatelZip Stockton, CA 95205 Phone (209)468-3000 Cross Street S B Street APN 155-18-002 Property Owner* San Joaquin County General Services Department - Phone (209)468-9598 Address 1810 East Hazellon Avenue City/State/Zip Stockton, CA 95205 C-67 Contractor Environmental Control Associates, Inc. License# C57-695970 Phone (831)662-8178 Address 3011 Twin Palms Drive CilylSlatelZip Aptos, CA 95003 ConsultanUSub-Contractor Condor Earth License# Phone (209)234-0518 Address 188 Frank West Circle, Suite I CilylState/Zip Stockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) 0 HAMMERa7RIVEN DIA.OF BOREHOLE 2.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS 0.125- TYPE OF CASING: ❑STEEL ❑PVC ® OTHER Teflon®or NylaBow tubing ❑ SOILBOWNG ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION fAk Sosoe.Ozo,w1 ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefiel Depth is 30 Ft) WEW SOIL BORING IDS SVP-1. SVP-p,SVP-3 GROUT SPECIFICATIONS granular bentonte seal,grout seal and Cush well box 6" DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: rCHECKALL THATAPPLYI If 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 [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED El AUGERS [I HOSE [I 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 �DD San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. j Signed l(d �' Title/Company PG#6795/Condor Earth Print Name John P. Lane Date 12/22/2022 EPARTMENT USE ONLY Application Accepted By: Date Issued: 2 3 �2a 2Z Grout Inspection By/Dales: -VLYLI Destruction Inspection By/Dates: Facilit /Site Information r/ FA Name FA Address FA# (jU PR# Q� FA PE 2 ) WP Reviewed By Work Plan Date j ❑C-57 C-57Authaizatbn(or Olherto Sign Permit ❑Workers Comp ❑Worker's Comp Waiver Encroachment Permit ❑Access Agreement lead Agency Approval R COMMENTSI ONDIT�IO/NS: I�f�(Tl � SDI v r Welk �„nr �� C� 5 Z 7� 1 5hk►` le �SIYoyZW 'dt+ SLPaYA e '� Lilo �ytOr �oN � P� L yr u� idzA p7 1 - 6 � d� �o s . WP TYPE I PE SC FEE INFO 2 AMT REMITTED CHECK# RECCVV'D BY DATE WELL PERMIT# INVOICE# Permit 2Ho1 313 S X i/ 6q ( �V I ,J 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138, w,.ssjjcehd.cc EHD 29-01 04-04-07 Site Mitigation Well Permt Application