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SANJOAQ� IN Environmental Health Department COUNTY 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 503 West Benjamin Holt Drive CltylStatelZip Stockton, CA 95207 Phone 209-944-5278 Cross Street Inglewood Avenue APN 081-260-52 Property Owner` Romero Management Services Phone 209-951-5090 Address 5713 TamwoTth Way citylstate/Zip Stockton, CA 95207 C-57 Contractor Gregg Drilling, LLC. License# 1044456 Phone 925-313-5800 Address 950 Howe Road CitylState/Zip Martinez, CA 94553 Consultant/Sub-Contractor Geosyntec Consultants, Inc. License# Phone 916-637-8048 Address 3043 Gold Canal Dr. City/State/Zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: OHsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH Uptol50ftbgs XBOLTED TRAFFIC BOX ❑STOVE PIPE �r X EXTRACTION vaporAYated 2 0 HAMMERmvEN DIAOFBOREHOLE IT ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL @PVC ❑ OTHER QA -20 ❑ SOILBORING [IPUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Bodng Die: Casing Dia: Casing p-Delhi ❑ INJECTION wspirw.omnel ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE INBPE ❑ OTHER © OTHER Senk GROUT SEAL PUMPED? ®Yes ❑No (Nate:Maximum Freelall Depth is 30 Ft) WELL/SOIL BORING IDs GEW-34A.GEW-340 GROUT SPECIFICATIONS Typell-V DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel WELL IDs ❑PRESSURE GROUT To depth of_feel below surface GROUT SPECIFICATIONS - ❑EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface g>3 feet COMMENTS: Two extraction wells will be installed with a maximum depth of 150' BGS. 1 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 _j� Title/Company Hydrogeologist/Geosyntec Consultants, Inc. Print Name Peter Dennehy, PG#9377 Date January 15, 2019 A MENT USE ONLY ®®L_X Application Accepted By: 'n Date Issued: `z �e Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information f, c� � FAName 1`r Acaln Cf�'w fQv% F Address P�>(iv Aria, VAFA - -' Y- ) ✓� 'T. AvY twc4. FA# OO ZI b 1 PRq os3-7 63 FA PE O WP Reviewed By - X Work Plan Date YJ /lq ❑C-57 57 Authodzakn for Other to Sign Permit orkers Comp ❑Workers Comp Waver ❑Encroachment Permit oxs,AgfWment ❑Lead Agency App wl FR COMMENTS/CONDITIONS: r WP TYPE PE I SC I FEE INFO JAMT REMITTEDI CHrEC c K# RECV'DD BY DATE WELL PERMIT# INVOICE# Permit ZM 31 j $152 x � j I -S L ,/1 I7 W 7 1868 E. H_azelton Avenue I Stockton/,(}rC. aliifforrnia 9520[5 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0to tt�i 4'15lx 3 L>ttts4 117.J Z Site Mitigation Well Pemtil Appliwtim vJ P ul 3