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Permit Application 2 of SAN JOAQUIN p �QUIN ��'°°� Environmental Health Department —COUNTY c9r, r 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 6471 Pacific Ave Clly'statelzip Stockton, CA 95207 Phone Cross Street Pacific Ave and W Benjamin Holt Dr APN 09741029 Property Owner* Lincoln Properties LTD Phone 209-478-9200 Address 374 Lincoln Center citylstatelzip Stockton CA 95207 C-57 Contractor Penecore Drilling License# 906899 Phone 530-661-3600 Address 220 N East St CitylStatelzip Woodland, CA 95776 ConsultantfSub-Contractor Geosyntec Consulting License# Phone Address 3043 Gold Canal Dr Suite 100 citylstatelzip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BodngstWells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapot/Water) ❑ HAMMERIDRIVEN 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 ❑ PUSH POINT(GP/CPT) CONOUCTORCASING ❑Yes ❑No Being Dia: Casing Dla: Casing Depth: ❑ INJECTION(ArSoave.ozo,w) ❑ 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) WEW SOIL BORING IDS GROUT SPECIFICATIONS fat?R.r� AM (16 t4. DESTRUCTION WORK TO BE PERFORMED: p DESTRUCTION METHOD: (CHECK ALL THAT APPLY) III WELLS TO BE DESTROYED 9 At N1-OD {t f . MVJ` 2D4D ,®OVER-BORE DIAMETER of inches todepth of 5 feet �/ WELL IDS See Attached t�1�OO kr41, P� GOS PaOIt ❑PRESSURE GROUT Todepthof feet below sudace � nd f GROUT SPECIFICATIONS Neat cement grout -3gal water tome 47lb bag of perueM cement NEXPLOS Fro 7 to t30 feel balm surface�'a«e j7r� TREMIE TYPE TO BE USED [I AUGERS ❑HOSE ®PIPE ❑I MMUS AP ❑3Tf� low sudace of feetfeel below urfatte/if>3 feel / COMMENTS)( �,-IOYLCtT ll7ll� r1`�AI'"� w 1(4 t See list of attached wells and well information.All IDW will be ha-red off by a hazardous waste certified company. Vlk 1 hereby certify that I am authorized to complete this application and that the work will be done in accordant with Joaquin County Ordinance Codes and Standards,and all other applicable California laws_-1� t $ ll�© P Signed Title/Company Project Geolo ist - Geos nTec GDnBulta C Print Name Jamie Purcell Dale 9�14/23 kY'rvl v fi DEJg RTMENT USE ONLY O Application Accepted By: Date Issued: r Grout Inspection By/Dates Destruction Inspection By/Dates: Facilit /Site Information FA Name " !C V 4a ( FA Address - FM O� _!;t)Q PR# FA PE WP Reviewed By x� Work Plan Dale a Zj 0C-57 7Authorization for Other to Sign Permit ❑WurkeJs Comp ❑Workers Camp Waiver ❑Encroachment Permit ❑Access Agreement my Approval COMMENTS/ NDITIONS: WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# I RECV-D BY DATE WELL PERMIT# INVOICE# Permit IZIOZ 1313 } X 5 1 8 1 (2 1 CL I 'n"') VJ Ij Aq 12-31Wtoo 44`4 1868 E. Hazelton Avenue I Stockton, California 9 205 1 T 209 468-3420 1 F 209 464-013 jceh .coin EHD 29-0104-20-23 cc Y�- 1 Z9 0 ;iI-q��0 Site Mi nation was Permit Application