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amu' SAN. DAQUIN Environmental Health Department —COUNTY — 41F 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 2459 E.Mariposa Rd City/State/Zip Stockton CA 95205 Phone None Cross Street 99 Frontage APN 171-300-24 Property Owner* James E.Blincoe Property Trust;Janet Blincoe,Trustee Phone 209-483-0638 Address 14501 Wells Lane City/State/Zip Lodi,CA 95240 C-57 Contractor Cascade Drilling License# 1058336 Phone 916-638-1169 Address 3000 Duluth St. City/State/Zip West Sacramento,CA Consultant/Sub-Contractor Parsons License# NA Phone 925-278-4100 Address 2.121 N.California Blvd. City/State/Zip Walnut Creek,CA 94596 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 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.5 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 3/16 inch TYPE OF CASING: ❑STEEL ❑PVC (A OTHER Direct push-dual tube ® SOIL BORING 5 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 SB-1 thru SB-5 GROUT SPECIFICATIONS 3 gal water per 47 Ib bag of cement 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 ❑EXPLOSIVES From to feet below surface TREMIE TvPE TO BE USED ❑AUGERS ❑HOSE [—]PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: We plan to advance each boring using dual tube drill rods to 50'.Remove the inner rods string while leaving the outer casing in place.Insert 3/4"PVC casing w/10'of screen to the bottom of the boring,retract the outer casing to expose the PVC screen.After collecting a water sample(if water collects in the borehole)use the PVC casing as a tremmie pipeo grout the borehole to th surface 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 ot!' _ - Title/Company P.E.Senior Engineer Parsons Print Name Jeffrey A.Gravesen Date July 2,2021 DEPARTMENT USE ONLY Application Accepted By: JEFF Y W NG / Date Issued: 7/8/2021 Grout Inspection By/Dates: 6 Destruction Inspection By/Dates: Facilit /Site Information FA Name JAMES BLINCOE PROPERTY TRUST FA Address 2459 MARIPOSA FA# FA0026667 PR# PR0547041 FA PE 2950 WP Reviewed By JW Work Plan Date 7/2/2021 ❑ 57 P C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit )p Access Agreement ❑Lead Agency Approval MFR COMMENTS/CONDITIONS: SUBMIT COPY OF THE REPORT/SAMPLING RESULTS TO EHD AS REQUIRED UNDER SJC WELL STANDARDS 13.7.2 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2905 313 $152- 5 760 CC JW 7/2/2021 WP0042257 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 Confirmation Number 127838889 SR0083941 Site Mitigation Well Permit Application