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SAN JOAQUIN Environmental Health Department 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 548 E. Park Street City/State/Zip Stockton, CA 95202 Phone 707-815-8807 Cross Street N American Street APN 139-165-04 Property Owner* Hendrik Valk Phone 707-815-8807 Address 548 E. Park Street. City/State/Zip Stockton, CA 95202 C-57 Contractor Gregg Drilling License# C57- 1044456 Phone 925-313-5800 Address 2100 Goodyear Road City/State/Zip Benicia, CA 94510 Consultant/Sub-Contractor Ground Zero Analysis License# PG 5023 Phone 209-522-4119 Address 1172 Kansas Ave, City/State/Zip Modesto, CA 95351 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 70 ft BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SHD40TYPE OF CASING: ❑STEEL $(PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING Q Yes ®No Boring Dia: 8 inch Casing Dia: 2 Casing Depth; 70 ft [I❑ INJECTION(Air Saarge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 55 ft TREMIE TYPE TO BE USED: ❑AUGERS HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs _W-12 GROUT SPECIFICATIONS Neat Cement, 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: For additional details, refer to 12/27/23 Work Plan approved by RWQCB 1 hereb certify that I 4m au rized to complete this application and that the work will be done In accordance with San Jowl finance Codes and Standards, and all other applicable Califomla laws. Signed % Title/Company Ground Zero Analysis, Inc. Print Name Gregory Stahl, .P. Date June 26, 2024 DEPARTMENT USE ONLY Applica v 'oted By: 4� v V Date Issued: < < / 2V 2 Grout Ins�. .don By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name f'q(� W r i .s FA Address z l� FA# N"` PR# FA PE 2q 60 WP Reviewed By --7-r"" WWork Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit Access greement ency Approv COMMENTS/C60TIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY D/�TE WELL PERMIT# INVOICE# Permit '� l� 4Z{ 2 CG V 0014 1868 E. Hazelton Avenue I Stockton, California 95205 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