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SA N.SJ OAQ U ni Environmen-L,,. Health Department COUNTY apt 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 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 630 N. California St. City/State/Zip Stockton, CA 95202 Phone Cross Street E. Oak Street APN 139-165-100-000 Property Owner San Joaquin County/Joshua Hernandez-Zavala Phone (209)953-7046 Address 44 N. San Joaquin Street, Suite#590 City/State/Zip Stockton, CA 95202 C-57 Contractor NA License# NA Phone NA Address NA City/State/Zip NA Cons ultant/Sub-Contractor John Lane, Condor Earth License# PG#6795 Phone (209)743-7443 Address 188 Frank West Circle, Suite 101 City/State/Zip Stockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 4.5-5ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 0OIL VAPOR PROBE [IMUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER VIIFSSOIL BORING 2PUSH POINT(GP/CPT) CONDUCTOR CASING Yes No Boring Dia: Casing Dia: Casing Depth: [I INJECTION(Air Suarae.Ozone) M [IHAND AUGER GROUT SEAL DEPTH NA 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 ��d HA3 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 [:1 EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED E]AUGERS [:]HOSE ❑PIPE [:1MUSHROOM CAP El3 feet below surface or feet below surface if>3 feet COMMENTS:pursuant to San Joaquin County Well Standards Section 13.6.2, work performed under the direct supervision of a Registered Geologist, where the total depth is less than 10 feet, is not required to be performed by a C-57 contractor I hereby certify that I am authorized to complete this application and that the work will be done in accordance with ` ..p San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed � L11---- Print Name John Lane, PG#6795 Date 11/30/18 DEPARTMENT USE ONLY Application Accepted By: � Date Issued: Iz 11,C;, Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information p FAName "` �r�Lu �` AAddress 5iN`� �'►��"�"`� FA# �vZ� PR# �y FA PE L WP Reviewed By L "Y Work Plan Date �a ❑C-57 ❑C-57 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval R COMMENTS/CONDITIONS:(;. ,` C �v..� s-,kA 4,&r v c„ �4-ue w-)v- 'v-��D 10wa��.. Som\ t,.k4...��, J L.wti� -%,t— WP TYPE PE sC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2� 31 $152 x � 3"1 Z, crS 1 , �,( 1 t,; l %VPG��'1(�` r 1868 E. Hazelton Avenue I Stockton California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17ite Mitigation Well Permit Application