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°�, SAKJ0AQUIN Environmental Health Department <br />COUNTY <br />Greatness grows here. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 180 East Weber Avenue City/State/Zip Stockton/California/95202 Phone (209) 992 - 5555 <br />Cross Street Weber and Hunter <br />Property Owner* Judicial Council of California <br />Address 455 Golden Gate Avenue <br />C-57 Contractor Pene Core Drilling Drilling <br />Address 220 N. East Street <br />APN 149-020-03 (right-of-way) <br />City/State/Zip San Francisco/California/94102 <br />License# 906899 <br />City/State/Zip Woodlands/California/95776 <br />Consultant/Sub-Contractor Ninyo & Moore Geotechnical & Environmental Sciences License# 697063 <br />Address 2020 Challenger Drive , Suite 103 City/State/Zip Alameda/California/94501 <br />Phone (415) 865 - 4200 <br />Phone 530-661-3600 <br />Phone 510-343-3000 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 30 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE Approx. 3" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER No Casing <br />IN SOIL BORING 2 CEJ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />[ZITHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs B-1 and B-4 GROUT SPECIFICATIONS Tremi-grout with neat cement <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /># WELLS TO BE DESTROYED N/A ❑ OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />SignedBnr �� Title/Company Senior Project Geologist / Ninyo & Moore <br />Print Name Bryan F°ng Date 11/19/2020 <br />Application Accepted By: �/ <br />Grout Inspection By/Dates—jam <br />Destruction Inspection By/Dates: <br />Facilitv/Site Information <br />Date Issued: <br />FA Name <br />FA Address <br />FA# <br />?? <br />PR# <br />''TT <br />FA PE <br />71& V <br />WP Reviewed <br />By <br />Work Plan Date <br />❑ C-57 Ej,657 Authorization for Other to Sign Permit <br />orkers Comp ❑ Worker's Comp Waiver g4croachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: SC <br />u ` <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />Cl HEC # <br />RECV-D BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit�! <br />$152 x <br />-LI /10 <br />1868 E. Hazelton Avenue I Stockton, California 95205 �T 209 468-3420 �F 209 464-0138 1 www.sjcehd.com <br />EHD 29-01 08-W-17 Site Mitigation Well Permit Application <br />