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SAN.,NJOAQUIN Environmental 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 1�(jsf d 33,5, 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 1610 N El Dorado Street City/State/Zip Stockton, CA 95204 Phone Cross Street Sperry Ave APN Property Owner* City of Stockton Phone Address City Right-of-Way, sidewalk on N side of Sperry Ave city/statelzip Orangevale, CA 95662 C-57 Contractor Cascade Drilling, LP License# 1058336 Phone 916-638-1169 Address 3000 Duluth St City/statelzip West Sacramento, CA 95691 ConsultanUSub-Contractor GHD Services, Inc. License# 17-00062639 Phone 530-558-1921 Address 4080 Plaza Goldorado Circle, Suite B City/State/zip Cameron Park, CA 95682 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsWells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS * MONITORING HOLLOWSTEM BORING DEPTH 83 fbg CREICILTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaponWater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE flinches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2inches ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS Schedule 40 TYPE OF CASING: ❑STEEL [KPVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes D(No Boring Dix: Casing Dia: Casing Depth: ❑ INJECTION IAk Soaoe.ezmel ❑ HANDAUGER GROUT SEAL DEPTH 64 fbg TREMIE TYPE TO BE USED: tRAUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes Callo (Note:Maximum Freefall Depth is 30 Fp WELU SOIL BORING Ds MW-23 GROUT SPECIFICATIONS Portland Type l/Il Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of feet WELL Ws ❑PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS El EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel 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 �62t- Title/Company Staff Geologist GHD Services, Inc. Print Name Ryan Bast Dale 0 9/2 312 01 9 D RTMENT USE ONLY Application Accepted By: Date Issued: © !Y� 0 Grout Inspection By/Dates: Destruction Inspection By/Dales: C Facilit /Site Information FA Name 0tw AAddress 5D 2 ' a rb raiA 1FA# OD O i 7- PR# os- aoo FA PE 4 Q WP Reviewed By Work Plan Dale r 3 O D ` ❑C-57 57AuthodzaUanfor0therto Sign Permit ❑Workers Camp ❑1 lWofrrkkels Camp Waver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS:50I 411* Ofo LD /'T-w w r ll, duA� S p r� ��Ga, ta)�1G @SJ if WP TYPE PE SC ii FEE INFO AMT-[REMITTTED CHECKK# I RECV'D BY I D '1TE r WELL PERMIT# -I_NV`OIICE# J J Permit Zoo( 31 $152 x I 152 YZ! ;k I N&11 Li ZV 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 290109A1-17 Srgtition ! t,licalioniMo1 >