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i SAN 10AQUIN p 2 �� Environmental Health Department COUNTY Greatness qrows 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 Rough and Ready Island City/State/Zip Stockton,CA 95203 Phone Cross Street WFyfrestreet APN 16203007 Property Owner* Port of Stockton Phone (209)946-0246 Address 2201 Washington Street City/State/Zip"Stooaoon,eA952oa- !P L�/3 0/ZOZ�L C-67Contractor Confluem.En11Aronmental (�, l J� Licens _ ��J PtIOnO (707)639-7709 Address 800 M Street o�c+d��SS Q(! L OYl �s l.p/ City/State io Linda,CA 95673 Consultant/Sub-Contractor Geosyntec Consultants Inc `T License# Phone (916)637-8346 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 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaree.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 3 , I`js #WELLS TO BE DESTROYED 15 ®OVER-BORE DIAMETER of inches to depth of feet WELL IDs See Attached GROUT To depth of feet below surface to E GROUT SPECIFICATIO S Neat cement gro -3gal water to one 471b bag of Portland cement ❑EXPLOSIVES From to feet below surface 5ems- J TREMIE TYPE TO BE U S ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feetT4 COMMENTS: 0 11J See list of attached wells and well information.All IDW waste will be hauled off by a hazardous waste certified company. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. ! Signed/ Title/Company Scientist,Geosyntec Consultants Jf LT Print Name Jennifer Martin Date 8/25/2023 DEPARTMENT USE ONLY /L Application Accepted By: _/ Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information _ FA Name 1��•hd �� 14 FA Address Sf FA# p Z`�f PR# 5 FA PE 2" WP Reviewed By -- Work Plan Date Z 20 7 ❑C-57 7 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement XLead Agency Approval 25MER C MMENTS/ NDITIONS: �:h _ ��C l.'i iYlc, CDJ�'�- 5� �`;✓S z� rYIS .f� r , - 1 �w tt�I �% �b�.►e XI.� S hou ;nCu►�h2k -Pev- rlsP�cflor ;ytcl, �/(v tme zS` w / b Q- ,Ikkvo' +r' y:«n ece- WP TYPE I PE I SC IFEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 1902,1313 s1L4R 5_ 1'- Z C+ lC l � � 3o Z�^� oo+L SZZ r �0 3 L) 1868 E. Hazelton Avenue I Stockton, Call rnia 95205 1 T. 209 468-3420 1 F 209 464-0138 WWW.s �hd.com EHD 29-01 04-20-23 1 b 6ci 50 Site Mitigation Well Permit Application L-f7>IO169 115 2&6