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SA N =]0AQ U 1 N Environmental Health Department —COUNTY— 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 andlor 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 2500 Navy Drive Citylstate/Zip Stockton, CA 95206 Phone 209.937.8460 Cross Street Ort J. Lofthus Fwy. APN 163-330-030-000 Property Owner` Art O'Brian/City of Stockton, Municipal Utilities Department Phone 209.937.8460 Address 2500 Navy Drive City/State/Zip Stockton, CA 95206 C-57 Contractor Tom Scott/Geo-Ex Subsurface Exploration License# 954267 Phone 916.799.8198 Address 1510 Madera Drive City/State/Zip Dixon, CA 95620 ConsultantfSub-Contractor Jose J. Asyn I Klelnfelder, Inc. License# 467252 Phone 209.327.0998 Address 2001 Arch-Airport Road, Suite 100 City/State/Zip Stockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 10 HOLLOW STEM BORING DEPTH 75 feet IN BOLT-ED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vaporfftter) ❑ HAMMERURIVEN DiA.OF BOREHOLE 4 to 6 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS - TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Airsnarge.ozone} ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ©PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? N Yes ❑No (Note:Maximum Freefall Depth is 30 Fla WELL)SOIL BORING IDs MIN-3 GROUT SPECIFICATIONS 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 Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed l Y TitWCompany Principal /Kleinfelder, Inc. Print Name Jose J.Asyn Date December 28, 2020 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver []Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR C OM M E N TSIC ON DITI O N S: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 J T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHO 2"1 0"1-17 Site Mitigation Well Permit Application