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o°'`�gIN•.c SAN JOAQUIN COUNTY <br /> 2` Z LN- ONM N 1 ❑ ❑ElP- M N <br /> Q: A <br /> Ya 18 8 I Ion n oc Idnf-C❑ r5205- 232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wvvw.s'cehd.com <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON- N PunM P - 1 -L OM <br /> -_. -IICCHon ii r y d o n03EMn Co ny or r li®con it c_=nd or in7__II :orild--cri. d. <br /> -ooslicOrwniC- uincoo oincc-iE-n - �nCooil to nuBdCi�r s1115.3_f.hd -n Cocmn Cony II _ndrrdo <br /> Job Address 872 W Benja . Holt Drive City/state/Zip Stockton, CA 95207 Phone <br /> Cross Street Pacific Avenue APN 097-410.80 <br /> Property Owner* Lincoln PropertiN Limited Phone (209)478-9200 <br /> Address 374 Lincoln Center City/Slate/Zip Stock , CA 95207 <br /> C-57 Contractor Gregg Drilling and Te ing, Inc. License# 10444 Phone (925) 313-5800 <br /> Address 950 Howe Road Cily/StatelZl artinez, CA 94553 <br /> Consultant/Sub-Contractor Geosyntec Co sullants, Inc. License# Phone (916)637-8048 <br /> Address 3043 Gold Canal Dr. City/S te1Zip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFOR ED: [Nobt O,*+p,1ri 1' AWre&ct0 gait V16orrf/ncro&AAEnf'Pereik S <br /> TYPE OF WELL/BORING NUMBER INSTALLATIO TYPE CONSTRUCTION SP CIFICATIOPONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORINGDEPTH Pt059b9s ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporM'ater) ❑ 14AMMERA)RIVEN DIA.OF BORER 1.5' ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THIC EBB TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCT CASING [I Yes [I No Boring Dia: Casirg Dia: Cnlrg Depth: <br /> ® INJECTIONIAksoay .A i 24 ❑ HANDAUGER GROUT LDEPTH TREMIE TYPE TO BE USED: ❑AUGERS El HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROU SEALPUMPED7 ITI Yes ❑No (Note:Maximum Freafall Depth is 30 FQ <br /> WELUSOILBORINGIDS DIP-OlthmughM R TSPECIFICATIONS Typell-V <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: rCLLCL LL U LL LPPLLL <br /> IfWELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑PRESSUREGROIIT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES Fromto_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE JPIPE ❑MUSHROOM CAP ❑3 feel below surface or feel below surface if>3 feet <br /> COMMENTS: 24 injection paints will be adva d to a maximum de h of 50 feet bgs. The borings vnll be lremie grouted once injections are complete. <br /> I hereby certify that I am authorized to complete thi ,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 /> ci1hA '\-11EICoC=11y Geologist/Geosyntec Consultants, Inc. <br /> PrinCNm C GameB Thomton,PG 9748 Lei September 5,2019 <br /> DEPARTMENT US ONLY <br /> AWic0ionAcce f6d/!ky: ❑oIDInd: <br /> (�rW[{�lffgc[ton By7iQ <br /> (�C4�cJion ln,�c�on �i� <br /> Facility/Site Informa t on <br /> FA Name FA Address F PR# <br /> FA PE WP Reviewed By Work Plan Dale <br /> ❑C-57 ❑C57AUNMZafian I"Olhsrla Sign PemJl ❑Workeescomp ❑Workefs Comp Waiver ❑EncroxWent Permit ❑Access Agreement ❑Lead Agencyppprova ❑MFR <br /> COMMENT /CONDITIONS: <br /> SR PE PE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> PerikiI C13oo <br /> ❑ ID 20O1 10-2D2015 rimMignifon WO1 PDoimmiclYon <br />