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%_' i7 oG2 SAN JOAQUIN Environmental Health Department \ — COUNTY °ge,FOQar/ GreuLness yrows 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 555 W.Benjamin Holt Drive City/State/Zip Stockton,CA,95207 Phone Cross Street Inglewood Ave APN 08126029 Property Owner' Miner Joagin Building Corporation Phone 209.929.1433 Address Po Box 1110 City/State/Zip Stockton/CA/9520 C-57 Contractor Gregg Drilling LLC License# 1044456 Phone 925.313.5800 Address 950 Howe Rd City/State/Zip Martinez/CA/94553 Consultant/Sub-Contractor GeosyntecConsultants Inc License# Phone 916.637.8048 Address 3034 Gold Canal Drive,Suite 100 City/State/Zip Rancho Cordova/CA/95670 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 110 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 0 SOIL BORING 3 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 0 Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs CPT 4-6 GROUT SPECIFICATIONS Type I I-V 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 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: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with oaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Geologist-Geosyntec Consultants Print Name Jamie Purcell Date 6/25/24 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name a ` r r t f FA Address L-' 1 j FA# OQ 7 3f '� PR# (`� I J FA PE �i( WP Reviewed By Work Plan Date 'Z 5/?0 ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit Access Agreement OLead Agency Approval Of MFR COMMENTS/CONDITIONS: — (' i i b i i "Zell �� 4.�1/:�✓ G w �, } rain.�L�Y`�-- WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Z10 13 $162 x T 00 10 r`Or►�Pi rtG� M 7H?'9UZ—q- kt C # 1'd 5 .. }` '.. i J R24'o 0 2 9 3 1868 E. Hazelton Avenue 5T oc on, Cali ornia 9520 T 209 468-3420 F 209 464-0138 1 www.sicehd.com EHD 29-01 7-01-2023 Site Mitigation Well Permit Application