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-iii SAN J 0 A Q U I N Environmental Health Department —COUNTY-- Greatness COUNTY-- Greatness qrows her, 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 240 Lincoln Center,858 West Benjamin Holt Drive City/State/Zip Stockton,CA,95207 Phone 916-637-8320 Cross Street Pacific Avenue APN 09741079 Property Owner` Lincoln Property,Ltd. Phone Address 374 Lincoln Center City/State/Zip Stockton,CA,95207 C-57 Contractor PeneCore Drilling License# 906899 Phone 530-661-3600 Address 220 N.East Street City/State/Zip Woodland,CA,95776 ConsultanUSub-Contractor Geosyntec Consultants License# Phone 916-637-8048 Address 3043 Gold Canal Dr.,Suite 100 City/State/Zip Rancho Cordova,CA,95670 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 50 feet M BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ® HAMMER/DRIVEN DIA.OF BOREHOLE 4„ ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ® OTHER teflon ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING [:]Yes ®No Boring Dia Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 10 ft.bgs TREMIE TYPE TO BE USED ❑AUGERS ®HOSE ❑PIPE ❑ OTHER --0,OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SO L BORING IDs SG-10 :SG-101 (pp to five soil vapor GROUT SPECIFICATIONS Grout to ground surface with anchoring cement. probes in e h DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED N/A ❑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: Install multiple depth soil vapor probe. Up to 5 probes will be installed.Maximum boring depth of 50 feet bgs. 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 -/,i -- Title/Company Senior Principal Hydrogeologist,Geosyntec Consultants Print Name A�hur Forma Date 5/22/2020 DEP TMENT USE ONLY Application Accepted By: ate Issu Z�— Grout Irspection By/Dates: Destruction Inspection By/Dates: Facilit !Site Information / FA Namen� s_V FA Address /_� r ' q0 C F # 0C>ZI f�� PR# D S FA PE �/� WP Reviewed By lJ" Work Plan Date �. I Zo ❑C-57 C-57 Authonzalion for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/ N (TIONS: t WP TYPE PE I SC I FEE INFO JAMT REM( TED CHEC # RECV'D BY DATE WELL PERMIT# INVOICE# Perm t13� $152x 52 Z( S 0 oO oq�0 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 46 - �'( .sjce d.corn EHD 29-01 08-01-17 Site Mitigation Well Permit Application