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•� �nuirv�* <br /> S A N J OAQ U I N Environmental Health Department <br /> J COUNTY <br /> °q�, %J Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 503 West Benjamin Holt Drive City/State/Zip Stockton CA 95207 Phone 209477-4868 <br /> Cross Street Inglewood Avenue APN 08126052 <br /> Property Owner' Romero Management Services Phone 209-951-5090 <br /> Address PO Box7959 City/State/Zip StocktonCA95267 <br /> C-57 Contractor Legacy Remediation License# 1066496 Phone 925-226-8181 <br /> Address 685 Stone Road,#18 City/State/Zip Benicia,CA 94510 <br /> Consultant/Sub-Contractor Geosyntec Consultants Inc License# Phone 530-771-7497 <br /> Address 3043 Gold Canal Drive,Suite 100 City/State/Zip Rancho Cordova CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 80 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: <br /> ® INJECTION(Air Soame.ozone) 7 points ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? QfYes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/ BORING IDS DP8 through DP14 GROUT SPECIFICATIONS Type II-V <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed A2�! Title/Company Project Geologist-GeosyntecConsultants <br /> Print Name Jamie Purcell Date 6/25/24 <br /> DEPARTMENT USE ONLY <br /> rr �- <br /> Application Accepted By: 7� Date Issued: <br /> ` <br /> Grout Inspection By/Dates: 6121 �ZQ✓��y� ��� �/1/j41 O� 45"- Il.L <br /> Destruction Inspection By/Dates: alitL <br /> Facility/Site Information <br /> FA Name FA Address r - ,f FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit Access Agreement ead Agency Approval aMFR <br /> COMMENTS/CONITIONS <br /> �. L4 4 <br /> WP TYPE PE Sc FEE INFO AMT REMITTFn1 CHECK# RECVN BY DATE WELL <br /> 7P�ERMIT# INVOICE# <br /> Permit !�0 313 p$162 x I.- ,1 � a n) � * 4- W 1 '-q-190�0 <br /> 1868 E. Hazelton Avenue I Stockton, California 65205 I T 209 468-3420 1 F 209 464- 138 1 www.sjcehd.com <br /> EHD 29-01 7-01-2023 ` Site Mitigation Well Permit Application <br /> GJ t:I <br />