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O C` SANsHAQ N Environmental Health Department COUNTY- 1QP Greatness grows here. 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 7AI 48 Hours Advance Notice Required For All Inspections " _S 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 520 E Park St. (640 N. California Street) City/State/Zip Stockton, CA 95202-2134 Phone Cross Street N. California Street APN 139-165-020-000 Property Owner* Jesse E Cooley Jr Properties LP Phone (559) 268-8048 Address PO Box 11612 City/State/Zip Fresno, CA 93774 C-57 Contractor Cascade Drilling License# C57#938110 Phone (916) 639-1169 Address 3000 Duluth Street City/State/Zip West Sacramento CA 95691 Consultant/Sub-Contractor Condor Earth License# PG#6795 Phone (209)234-0518 Address 188 Frank West Circle, Suite I City/State/Zip Stockton, CA 95206 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 25 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.5 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA EJOOIL VAPOR PROBE UD ROTARY CASING THICKNESS NA ff TYPE OF CASING: [3STEEL [IPVC [IOTHER SOIL BORING 1 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes VFNo Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH NA TREMIE TYPE TO BE USED: [:1AUGERS [:1HOSE [IPIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes'fil6o (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GP-5 GROUT SPECIFICATIONS NA 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 [:13 feet below surface or feet below surface if>3 feet COMMENTS: Direct push soil boring/groundwater sample to 25 feet. 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 c� �^< ---- Title/Company P(;#Fi795/Cnndnr Earth Print Name John P. Lane Date 5/13/19 // DEPARTMENT USE ONLY Application Accepted By: x1dEt,'4" Date Issued: ��— Ldp!f Grout Inspection By/Dates: Destruction Inspection By/Dates: 20 Facilit /Site Information FA Name �,, 3�+ � 121 w S R04FA Address FA# PR# s- 315-0 FA PE Z 0140 WP Reviewed By S�6vv, Work Plan Date S-_30-11 ❑C-57 ErC-57 Authorization for Other to Sign Permit [Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit [Access Agreement [Lead Agency Approval tR'MFR COMMENTSICONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit zq#6— -tL3 $152x o 6( v5-Z-` 1543 fvW' S->9-17 'A~3167If 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com Warp-pj'. EHD 29-01 oa-Ot-17 ,Site Mitigation Well Permit Application w- 2413 ,j'z3 Jl/SZ X3 �P s G Go ��?'3 ,�0V.*04 f,