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Permit Application 3of4 SAN JOAQUIN Environmental Health Department COUNTY oBN 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 vdth San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 818 W Lincoln Road City/State/zip Stockton, CA 95207 Phone 209-953-8652 Cross Street W Lincoln Rd and Pacific Ave APN 09741002 Property owner Lincoln Unified School District Phone 209-953-8700 Address 2010 West Swain Road City/State/zip Stockton/CA/95207 C-57 Contractor Penecore Drilling License# 906899 Phone 530-661-3600 Address 220 N East St citylstatelzip Woodland, CA 95776 Consultanbsub-contractor Geosyntec Consulting License# Phone Address 3043 Gold Canal Dr Suite 100 city/state/zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION NaporMaler) 0 HAMMERIDRNEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONWCTORCASING ❑Yes ❑No Boring Dla: Casing Dix. Casing Depth: ❑ INJECTION(AYS9aoo.o,1 ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes [I No (Note:Maximum Freefall Depth is 30 Fg WELL/SOIL BORING us GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMPTER of inches to depth of � WELL IDS Pz-011A ❑PRESSURE GROUT To de of feet below surface GROUT SPECIFICATIONS Neat cement grout -3gal water tome 471E bag 0Pm.nd cement ®EXPLOSIVES From to ae feel below sudace TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE`®PIPE /n��❑A MUSHROOM CCAAP ❑3 f et below uda e or feet below fsurface iiff>3 fee COMMENTS:( Q2 o-t�a�i� yv� t)Q_Tr01A r—" t 6' r -1CJ" k &C-- C1', See list of attached wells and well Information.All IDW vdll be hauled off by a hazardous waste certified company. 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with x' Joaquin County Ordinance Codes and Standards, and all other applicable California laws. L h1 \ s Signed /.�L`�'� Title/Company Project Geologist - Geo�syntec�Consulta Print Name Jamie Purcell Date 9/14/23 3 DEPARTMENT USE ONLY / 7n Application Accepted By: Date Iss a Grout Inspection By/Dates: )N� Destruction Inspection By/Dates: FacilithriSite,Information A FA NameSo 411J r FA Address �[� G S ,ti FA# O�C, PRp d FA PE WP Reviewed By Work Plan Date l Z ' 0C-57 C-57 Authorizagon for Other to Sign Permit ❑Workers Gaup ❑Workers Comp Waker ❑Encroachment Permit ❑Access Agreement &LLpji1AjWenCyApProVaI MFR COMMENTS/CONDITIONS: WP TYPE PE I SC I FEE INFO AMT RFNlrrTEDj CHECK# I RECV'D BY I DAT WELL PERMIT# INVOICE# Permit - 02 13 lilx 1 I1 GC 7,3 w9aol+L+90 q 1868 E. Hazelton Avenue l Stockton, California 95205 l T 209 468-3420 l F 209 464-0138� VVwW.sjcehd.4 EHD29-0104-20-23 Cc 1 W ? : / p 0 Site Mibguon well Pemit Apphubon