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SIN JOAHIN Environmental Health Department —COUNTY— 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) 963-7697 For INSPECTIONS Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work descdbed. This application is made In compliance Wth San Joaquin County Development This,Chapter 9.1115.3,and the San Joaquin County Well Standards. - Job Address 1550 W Fremont St City/Statealp, Stockton,CA 95203 Phone Cross Street N Pershing Ave APN 135-110-180-000 Property Owner- Golden Bear Insurance Co. Phone 209-471-7197 Address 1550 W Fremont St CItylStatelZlp Stockton,CA,95203 C-57 Contractor Geocon Consultants,Inc. License# C57,716050-A Expires 12/31/2025 Phone B16.852.9118 Address 3160 Gold Valley Dr.Ste 800 CItylState/Zip Rancho Cordova,CA 96742 Consultant/Sub-Contractor Address License# Phone - CltylState/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsile BodngsM/ells Require Access Agreements or Encroachment Pantie TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH is ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaPwMalel) ❑ HAMMERARIVEN DL40F BOREHOLE 2.2V ❑MULTIPLE CASINGS❑MULTI-EVELWELLCASING DIA ❑ SO4LVAPORPROBE 0 MUDROTARY CASING THICKNESS TYPEOF CASING: ❑STEEL ❑PVC 0 OTHER ® SOILBORING 3 ❑ PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes ONO Being Die: CasMg DIX casing Depth: ❑ INJECTION atsom..snme 0 HANDAUGER GROUTSFALDEPTH TREMIETYPETOBEUSEO: OAUGERS OHOSE OPIPE ❑ OTHER {a OTHER DimdPOsh GROIITST:ALPUMPE01 ❑Yes ❑No (NOie:Mawiwm Freefal Depth is 30 Fit WEWSOILBOPJNGIDs GROUTSPECIRCATKINS Neal Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:PCHECKALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of—Inches to depth of feet WELL IDs ❑PRESSUREGROUT To depth of_feel below surface GROUT SPECIFICATIONS El EXPLOSIVES From—to—feelbeiow surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feelbefow surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the workwlll be done In accordance with n San Joa lu n County Ordinance Codes and Standards,and all other applicable California laws. Signed,/Grz��•, TillelCompany Construction Services Mana er/Geocon Consultants Inc. f Print Name ROBERT M.KIMBALL Dale 4 i oa y �7 PARTMENT USE ONLY ^� Application Accepted By: AY Dale Issued: Grout Inspection By/Dal . W S-r Destruction Inspection BylDates: FacilltviSite Information FAName Z_ ;, FAAddress f� ' �.w FA# 10 1 Pig D Ig FA PE WPReviewed By Work Plan Dale 8 z 0057 ❑C57A0ftrin5DnfrONerbSlgn Permit OWekersCamp OWakeesCompWalver ❑EmesdmenlPermtt OAo sAgmemenl OLeadAgencyAWevd OMFR COMMENTS/CONDITIONS: JWPTYPEJ PE I SC I FEE INFO JAMT REMITTED CHECI(#I RECV'D BY I DATE WELL PrRMIT# INVOICE# Permit 2405 31 $172x 2. $ 3 44- 1 CC 6W I 9LR-JZ W Z 1 oo 1668 E. Hazellon Avenue I Stockton, Califoro 962051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com EHD29-010e-20-23 1 log 3 ro 4 _7,q Site MilgaaoO Wd Permit APpeceem