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SAN J O A Q U I ll Environmenwi 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 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 1211 South Wilson Way City/State/Zip Stockton Phone 209-466-2764 Cross Street East Charter Way APN 151-350-06 Property Owner" Mary Martin-Martin Family Trust Phone 209-608-4185 Address 195 West Barstow Ave, Apt A City/State/Zip Clovis, CA 93612 C-57 Contractor Cascade License# q 3 8 6l V Phone 916-638-1169 Address 3000 Duluth St. City/State/Zip West Sacramento, CA 95691 Consultant/Sub-Contractor Green Environmental Management License# Consultant Phone 916-677-9897 Address 5098 Foothills Blvd, Suite 3-146 City/State/Zip Roseville, CA 95747 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH five(5)feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 4 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER M SOIL BORING three 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSoame.Ozone) ❑ HAND AUGER X GROUT SEAL DEPTH five(5)feet 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 S13-1, SB-2, SB-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 r r s — Title/Company Green Environmental Management Print Name Lita D. Freeman Date 3-19-2019 DEPARTMENT USE ONLY I Application Accepted By: Date Issued: Grout Inspection By/Dates: OS Destruction Inspection By/Dates: Facilit /Site Infor tion FA Name — Oa 4 FA Address I Zt1 - l N FA# 007,!g_1_10 PR# VSyy ZIP FA PE WP Reviewed By / Work Plan Date 1-3 LeA ❑C-57 5757 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval 9KFR COMMENTS/CONDITIONS: p- . •k w.+I., 'a4 ov, WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT## INVOICE# Permit VI US t 3 3 $152 x t Lj S(o C114 1 L—X 0 C 00 3114 t! 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29.01 08-01-17 �Q `�� `,� �' L �/ 3 t Ste Mitigation Well P rrnit Application