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SA N J OA U I N Environmental Health Department <l . tnI;! COUNTY ilmoR� Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 2150 West Alpine Avenue City/State/Zip Stockton, CA 95204 Phone 209-610-8766 Cross Street Franklin Avenue APN 11110001 Property Owner* Melvin Young - Centro Mart Inc. Phone 209-610-8766 Address 6507 Pacific Avenue, #335 City/State/Zip Stockton, CA 95207 c-57 Contractor Environmental Control Associates, Inc. (ECA) License# 695970 Phone 916.417.6858 Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 Consultant/Sub-contractor Partner Engineering and Science, Inc. License# NA Phone 559.907.7502 Address 1544 Eureka Road, Suite 180 City/State/Zip Roseville, CA 95661 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Welis Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.5 i [I MULTIPLE CASINGS El MULTI-LEVELWELL CASING DIA SOIL VAPOR PROBE ElMUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes LXNo Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air saarge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH U N K TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE Xi PIPE ❑ OTHER X OTHER:Direct Push GROUT SEAL PUMPED? X Yes ❑No (Note Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs 13TI r u h 135 GROUT SPECIFICATIONS Urout via OU nty rpquirements. Neat Cement Via Trpmi,- Pip . b Q I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK LL TH T APPLY) csowj Poe I:, Etc.GKy1 6 y l'• cv�rdfc� � #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth 6f feet rt rsn WELL IDs ❑PRESSURE GROUT To depth of feet below surface """"`. I r' GROUT SPECIFICATIONS El EXPLOSIVES From to feet below surface 0 F `T 110 TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet W COMMENTS- 'Temporary soil gas probe to be installed within each building at 5 feet bgs. 444 1 e y ertify 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-Partner Engineering and Science Inc. Print Name Laure Hinch Date 5/3/2022 DEPARTMENT USE ONLY / Application Accepted By: Date Issued: 22 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information 1'I FA Name 0 f FA Address L 1 SO Vv A FA# �� I PR# 0 �� FA PE ` WP Reviewed By Work Plan Date ❑C-57 7XIC-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access A eement ❑Lead Agency Approval FR COMMENTS/ N ITIONS:Aee,5,5 by ,Qw-A '&Uva Iroa / o.( ?Mprkv0101% N 0 'I' rs M WP TYPE PE SC FEE INFO AMT EMITTED CHECK# RECV'D Y DATE WELL PERMIT# INVOICE# Permit Z1313$152 x 3LIZ U i AQ 0 Lt 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34 w.0 F 20 a464-014�wwsj�ePcom EHD 29-01 08-01-17 (04 0 I�-3 �'�t.l. 94-2— � � p�p L'ln site Mitigation Well Permit Application