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S A N J 0 A Q U I N Environmental Health Department COUNTY-- c�elvoa� 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. JobAddress Pacific Ave Frontage road,see attached map City/State/Zip Stockton,CA,95207 Phone Cross Street W Benjamin Holt Dr and Pacific Frontage Road APN N/A Property Owner' City of Stockton public right of way Phone Address SeeattachedMap City/State/Zip C-57 Contractor Gregg Drilling LLC License# 1044456 Phone 925.313.5800 Address 95OHoweRd City/State/Zip Martinez/CA/94553 Cons ultant/Sub-ContractorGeosyntec Consultants Inc License# Phone 916.637.6048 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 WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 110 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 3 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarge.Ozone) ❑ 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) WELU SOIL BORING IDs CPT 1-3 GROUT SPECIFICATIONS Type II-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 an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Geologist-Geosyntec Consultants �092f Print Name Jamie Purcell Date 6/25/24 DEPARTMENT USE ONLY Application Accepted By: _Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name 4 j A FA Address � �^ FA# Q Z d PR# (� 4�j FA PE WP Reviewed By an Data ❑C-57 C-57 Authorization for Other rtto Sign Permit ElWorker's Comp [I Worker's Comp Waiver ❑Encroachment Permit, ❑Access Agreement' ❑Lead Agency Approval NFR COMMENTS/ ITIONS: � ((l t y I `> 611�5 L c Ir' �9 +-c� k - - Imo. __C;—11-.. '' l�, ` • ` {� (� ":^+1 t tic l?t9 10� � 0.�` I1fEJ� �L�r' r+v}t� �-3�dY�',,tTi^� l WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE ',1 WELL PERMIT# INVOICE# Permit 2905131 $162 x 6 Cv 2� �Z Vj P d0 1OLf CowC- uri. -lz9luut- C C 4a� 11 y SJzzt-roo Zq3 1868 E. Hazelton Avenue I Stockton, California"65265 I T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-017-01-2023 Site Mitigation Well Permit Application