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ul) „- �f SAN JOAQUIN Environmental Health Department Imo ? . t ' COUNT Y Greatness grows 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 148 N . Wilson Way City/State/Zip Stockton , CA 95205 Phone 209 -462 -5659 Cross Street N . Wilson Way & Channel ST . APN 153 - 050 -010 - 000 Property Owner* San Joaquin Marketing Association Phone 209462 -5659 Address 122 N . Wilson Way City/State/Zip Stockton , CA 95205 C -57 Contractor Encon Technologies , Inc . License# 748576 A - HAZ , C57 Phone 562 -777 -2200 Address 12145 Mora Dr . Suite 7 City/State/Zip Santa Fe Springs , CA 90670 Consultant/Sub-Contractor Encon Technologies , Inc . License# 748576 A- HAZ , C57 Phone 562 -777 -2200 Address 12145 Mora Dr . Suite 7 City/State/Zip Santa Fe Springs , CA 90670 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 2 ❑ 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 S1371S138 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED , DESTRUCTION METHOD : (CHECKALL THAT APPLY) # WELLS TO BE DESTROYED NIA ❑ 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 .a A j07 rh reby cert ' at I authorized to complete this application and that the work will be done in accordance with r< y Ordinance Codes and Standards , and all other applicable California laws . Signed Title/Company President , Encon Technologies , Inc . Print Name G . Joseph Scatoloni Date 12/29/2021 D PARTMENT USE ONLY Application Accepted B Date Issued : PP P Y Grout Inspection By/Dates : Z Destruction Inspection By/ Dates : Facilit /Site Information FA Name Z FA Address Z S M FA# Z PR# O FA PE - V WP Reviewed By Work Plan Date iC 57 ❑ C- 57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit VAccess Agreement ❑ Lead Agency Approval OWR COMMENTS/CONDITIONS : fib ` o ric, Ire, 5 a lS + 0 (::;P i j WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PPERMIT# INVOICE# i Permit VQ,57 1 $ 152 x ? ac� S W Poo _I 2$ - 1 Q5r I � ; I'�ti�c✓'Y� � ��7 � �� z2p � 5 � 00 A � �' 1� 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 01 8 1 www . sjgov . org /ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application