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S A N J O A Q U I N Environmental Health Department COU NIT Y 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 1200 Humpfreys(See Work Plan) City/State/Zip Stockton,CA 95203 Phone (209)946-0246 Cross Street (See Work Plan) APN 16203007 Property Owner Port of Stockton Phone (209)946-0246 Address 2201 West Washington St City/State/Zip Stockton CA 95203 PeneCore Drilling (530)661-3600 C-57 Contractor g Inc. License# 906899 Phone Address 220 N.East Street City/State/Zip Woodland,CA 95776 Consultant/Sub-Contractor Geosyntec Consultants License# Phone (510)836-3034 Address 1111 Broadway 6th Floor City/State/Zip Oakland,CA 94607 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ft bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE --3 1/4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA IM SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air soaroe.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs (See Work Plan) GROUT SPECIFICATIONS(See Work Plan) 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 Joaqui courlty Ordinance C res;and Standards,and all other applicable California laws. Signed �. Title/Company Senior Geologist Print Name Kimberly Brandt Date 05/23/2019 DEPARTMENT USE ONLY e Date Issued: Application Accepted By: /VgS l�k'"" ��im�► Grout Inspection By/Dates: Destruction Inspection By/Dates f Facilit /Site Information FA Name o YHt (rF �o c k kon EFAddress I ZW RU k FA# 2 0�0 PR# Sy D Q'FA PE Z Reviewed By N,jS66V& Work Plan Date 9t 0 ❑C-57 C-57 Authorization for Other to Sign Permit O'Workees Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement R(Lead Agency Approval 21AFR Of COMMENT S �/C ONDITIONS: /9LL Ca�d'ge'-P 3 .1 1(� Jo � Vai�� 'e,6C 4te- h ctft �G ��N��icf �(wi7?�/�t�.�fi� O, Y WP TYPE PE 73,'3 EE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 23D f ys�.od �3d G�7'�� ' wjtp/O a yG �d 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 OB-01-17 Site Mitigation Well Permit Application i:UOfk P,1�" J-903 s ''3 1�y yX 3 .✓ytG•� Sao /PW G-7—i9 �.e�rJ.0V710'