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SAN . J O A Q U I N Environmental Health Department COU NTY 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 7650 Newcastle Rd City/State/Zip Stockton,CA 95215 Phone Cross Street Arch Rd APN 181 140 13 Property Owner* Josh Mills Phone 209-607-6377 Address 7650 Newcastle Rd City/State/Zip Stockton,CA 95215 C-57 Contractor License# Phone Address City/State/Zip Consultant/Sub-Contractor Arcadis,U.S.,Inc. License# Phone 805-706-2805 Address 735 Tank Farm Road,Suite 150 City/State/Zip San Luis Obispo,CA 93401 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL(BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ;E] MONITORING 2—❑ HOLLOW STEM BORING DEPTH 95 ft ❑BOLTED TRAFFIC BOX STOVE PIPE 6 EXTRACTION(Vapor/Water) 1 ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 12 inches,8 inches [3y MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: 29 STEEL 8 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? E Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs —CUCT�-�-11, CDCR-PZ-1, GROUT SPECIFICATIONS portland cement CDCR-PZ-2 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 IN ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ElHOSE ElPIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 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 Assistant Project Manager/Arcadis Print Name Dalia Rumani Date 3/29/2022 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/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