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S A N J O A Q U I N Environmental Health Department COU NTY— !.� Greotriess grows het L. 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 602 N. California St. City/State/Zip Stockton, CA 95202 Phone 209-464-1282 Cross Street Oak St. APN 139-165-09 Property Owner* Gary Stallworth Phone 209-430-6022 Address 1107 Burkett Ave. City/State/Zip Stockton, CA 95205 C-57 Contractor TEG License# 706568 Phone 916-853-8010 Address -11350 Monier Park Place City/State/Zip Rancho Cordova, CA 95742 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 WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5-10 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 1 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 0 SOIL VAPOR PROBE 2 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 0 SOIL BORING L ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth ❑ INJECTION(Au Saaroe.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: Cl AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ es ❑No (Note:Maximum Freefall Depth Is 30 Ft) WELU SOIL BORING IDs VP-1,VP-2,24-SB-1 GROUT SPECIFICATIONS A. i ►�� DESTRUCTION WORK TO BE PERFORMED: 'DE��Rl7 T10 ETHOD: (CHEYK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet�� d �� WELL IDs ❑PRESSURE GROUT To depth of _feet below surface ba 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: 12/27/23 Workplan appr ved by RWQCB I hereb ertify that I aqauth,-Qd&Ato complete this application and that the work will be done in accordance with T San Joaqui �,,"r a.-Oodes and Standards, and all other applicable California laws. Signed Title/Company Ground Zero Analysis, Inc. Print Name Gregory Statittr V P. f Date May 14, 2024 � DEPARTMENT I SE ONLY Application Accepted By: 1400, , Date Issued: Grout Inspection By/Dates:!- i t Destruction Inspection By/Dates: FA Name �p r FA Address d '- FA# _ PR# at� FA PE (� WP Reviewed By Work Plan Date ❑C-57 ❑G-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement 04ead Agency ApprovVIGIMFIR l COMMENTS/CONDITIONS: . WP TYPE PE Sc FEE INFO JAMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# Permit 90 ' $162 x �� z3 3 + I Sol g$( 4'ytf Ry TCC Cflit 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 MiMgation Well Permit Application