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S A N J DA Q U I N Environmental Health Department COUNTY— SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7Ad BUILDING 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Z o pplication is hereby made to San Joaquin County for a permit to construct and/or install the work described. >do ' made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin Count Well Standards. YJob dress 50 South Wilson Way City/State/Zip Stockton, CA 95205 Phone Cross street- E. Charter Way (E. Dr. M.L.K. Boulevard) APN 155-12-007 Property Owner* _Fairgrounds Industrial Park Phone 209-462-8538 Address 749 29th Avenue City/State/Zip San Francisco, CA 94121 C-57 Contractor Cascade Drilling License# 1069034 Phone (925) 849-6970 Address 120 S. 23rd Street city/state/zip Richmond, CA 94804 Consultant/Sub-Contractor CDIM Engineering, Inc. License# 1020239 A HAZ Phone 415-498-0535 Address 45 Polk Street, 3rd Floor City/State/Zip San Francisco, CA 94102 to be completed as temp.soil vapor probes. CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 feet ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.25 inches ❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA X SOIL VAPOR PROBE 4 ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ® SOIL BORING 6 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(APSnaroe.ozone) ❑ HANDAUGER GROUTSEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ THE Direct Push GROUT SEAL PUMPED? []Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDS Soil and soil vapor-MMF-SS-01/MMF-SV-01•MMF-SS-02/ TSPECIFICATIONS MMF-SV-02, MMF-SS-03/MMFSV-03, MMF-SS-04/MMFSV-04,MMFSS-05/MMFSV-05 Soil vapor only:MMFSV-06,MMF-SV-07, MMFSV-08, MMF-SV-09 Soil only: MMF-SS-06 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 All temporary bod s/soil va robe ' ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS El HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: All soil vapor probes will be temporary an over-drilled Soil borings and over-drilled soil vapor probes will be destroyed by grouting using a tremie pipe. I hereby certify that I am authorized to complete this application and that the work will be done In accordance with S�p,Joaq my Ordinance Codes and Standards, and all other applicable California laws. Signed 6: Title/Company BU Manager / Cascade Print NameChristopher Tatum Date10/20/2022 DEPARTMENT USE ONLY Application Accepted By: L- Date Issued: I b Z Grout Inspection By/DateS:7 Destruction Inspection By/Dates: Facilit /Site Information FA Name ar FA Address L J 0 SCA FA# 6 Z Q PR# Q S o 3 FA PE WP Reviewed By ! Work Plan Dale ��26 Zr�z • rr •tt, r�ZZ lt&C-57 ❑ G57 Authorization for Other to Sign Permit ❑Worker s Comp ❑Workers Comp Waiver ❑Encroachment Permit El Access Agreement ' Lead Agency Approval O'MER li COMMENTS/CONDITIONS: 5 A mi CY L ok 01 S /� WP TYPE aPE SC F INFO AMT REMITTED CHECK# RECV'D B D TE /WELL PERRMIT# INVOICE# Permit 2_{�� 3 !Z 2x 2 r 10 ZV Vv 10 f +06U v Corr f'r m ( 5 16 9 �j 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464 0138 wwGv.sjce d cor�� 6 EHD 29-01 04-04-07 Site Mitigation Well Permit Application