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°" c�'74 SAN JOAQUIN Environmental Health Department \"' COUNTY 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 374 Lincoln Center City/State/Zip Stockton CA95207 Phone 209-477-4868 Cross Street Pacific Ave and W Benjamin Holt Drive APN 09741079 Property Owner* Lincoln Property Limited Phone Address 374 Lincoln Center City/State/Zip StocktonCA95207 C-57 Contractor Legacy Remediation License# 1066496 Phone 925-226-8181 Address 685 Stone Road,#18 City/State/Zip Benicia,CA 94510 Cons u lta nt/Su b-Contractor Geosyntec Consultants Inc License# Phone 530-771-7497 Address 3043 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 70 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 In ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: la INJECTION(Air Soarge.Ozone) 7 points ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? P Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL!SOIL BORING IDs DP1 through DP7 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 Joaquin 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 I _ Application Accepted By: ;`!. L Date Issued: r r' Grout Inspection By/Date Destruction Inspection By/Dates: Facilit /Site Information FA Name r ( (,(Z FA Address 4,1 y� y, ` ! i Jc %l FA# p p Z 3 o U PR# FA PE r WP Reviewed By ✓:�' Work Plan Date ZS hO Vq ❑C-57 ❑ -57 Authodzation for Other to Sign Permit ❑Worker's Comp ❑Worl�ers'Comp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency Approval FIR COMMENTS/CONDITIONS: Lr ��Q✓ � � (�(/�,(;L c�r s 13 •� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'Dyy BY DATE/ WELL PERMIT# INVOICE# Permit 2 31 $162 x 6 C C, J W 2� , Z� W z� Dol '7-lz 9luint C C-A 1 3 �� Zq 3 1868 E. Hazelton Avenue I`5fockton, California 9520 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29.01 7-01-2023 Site Mitigation Well Permit Application