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SAN ) O A Q U I N Environmental Health Department 'r•,tom&4-, COU N T Y--- Greatness O.Ows 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 09741060 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 Consultant/Sub-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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 50 feet ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ® HAMMER/DRIVEN DIA.OF BOREHOLE 4" ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC M 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 ElOTHER: GROUT SEAL PUMPED? ®Yes ElNo (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SG-10018G-101(up to five soil vapor GROUT SPECIFICATIONS Grout to ground surface with anchoring cement. probes i ch) 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 a multiple depth soil vapor probes. 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. i Signed Title/Company Senior Principal Hydrogeologist,Geosyntec Consultants ��--- Print Name Arthur Forma Date 5/22/2020 EPARTMENT USE ONLY Application Accepted By: ^.T Date sued: O Grout Inspection By/Dates: 14 Destruct on Inspection By/Dates: ' Facilit /Site Information FA Name 4�./ � v ��M FA Address ( Q�� C Z(fO G0�d� FA# OQ 2`J PR# a1 s FA PE vvv444 0 WP Reviewed t By r , , k Work Plan Date 2010 ❑C-57 -57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver [],Encroachment Permit ❑Access Agreement,❑Lead Agen y Approval ❑MFR COMMENTS/ NDITIONS: �O Ems` n �(—� OIyS d U L e C des I , WkW 12 to WP TYPE I PE I SC FEE INFO JAIIAT REMITTEDHEECI�Kf# RECV'D BY DATE WELL PERMIIT## INVOICE# Permit Z l 3 $152 x 3C) VJf 00ItOq Y1 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 46 -013 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application