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SAN J U A Q U IN Environmental Health Department COUNTY Greatness grown here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 COS ROW to 821 S Wilson Way(see attached map) City/State/Zip Stockton,CA 95205 Phone 209-937-8444 Cross Street E.Worth Street APN N/A Property Owner* City of Stockton Phone 209-937-8444 Address 425 North EI Dorado Street City/State/Zip Stockton,CA 95202 C-57 Contractor Advancedceo,Inc. License# 1063765 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 Consultant/Sub-Contractor Slagle Drilling Corperation License# 1046151 Phone (916)363-9355 Address 11345 Trade Center Drive City/State/Zip Rancho Cordova,CA 95742 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 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ 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 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 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED Six(6) ®OVER-BORE DIAMETER of 8 inches to depth of 50-55 feet WELL IDS MW-3,MW-4,MW-7,MW-8,MW-9,MW-10 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland type II cement to surface grade ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ®AUGERS [IHOSE [IPIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: MW-7 through MW-10 will be over drilled to 55 feet bsg with 8-inch hollow stem augers MW-3 and MW-4 will be over drilled to 50 feet bsg with 8-inch hollow stem augers 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 Title/Company Staff Geologist,AdvancedGeo, Inc. Print Name Evan Schmidt Date August 3rd,2021 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application