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SHAUN N�J O A Q U I N a Environmental Health Department COU NTY Grectness 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 Addiress Ten Mile Slough Levee, Brookside Road City/State/Zip Stockton, CA, 95219 Phone Cross Street March Lane APN 11603004 Property Owner* Reclamation District 2074 - George V. Hartman, District Counsel Phone (209) 956-9940 Address 3425 Brookside Road City/State/Zip Stockton, CA, 95219 C-57 Contractor Gregg Drilling, LLC License# 1044456 Phone (925)313-5800 Address 950 Howe Road City/State/Zip Martinez, CA, 94553 Consultant/Sub-Contractor KANE GeoTech Inc. License# Phone (209) 472-1822 Address 7400 Shoreline Drive City/State/Zip Stockton, CA, 95219 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 5 1@ HOLLOW STEM BORING DEPTH 3 0-4 0 f t ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 6-8 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 11 mm TYPE OF CASING: ❑STEEL El PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AV Soaae.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) WELUSOILBORINGIDs GROUT SPECIFICATIONS Cement grout, must be tremmied. 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: (4) 30-ft and (1) 40-ft PVC inclinometer casing(s) to be installed vertically to monitor levee stability. I hereby certify that 1 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 Staff Engineer/ KANE GeoTech Inc. Print Name Brian Forsthoff Date 2/17/2021 DEPARTMENT USE ONLY Application Accepted By: Aaron Gooderham Date Issued: 2/23/2021 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name Ten Mile Slough Levee FAAddress 0 Brookside Road FA# FA0026436 PR# PR0546596 FA PE 2950 WP Reviewed By AG Work Plan Date Feb. 12, 2021 ❑C-57 -57 Authorization for Other to Sign Permit orker's Comp ❑Workers Comp Waiver ❑Encroachment Permit Access Agreement ❑Lead Agency Approval FR COMMENTS/CONDITIONS: Please call inspection line 48 hours prior to grouting, EHD staff shall be present to observe grout placement. WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2901 313 $152x 5 $760.00 CARD AG 2/23/2021 WP0041727 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2M1 08-01-17 Confirmation Number: 121026898 SR00833:V Mitigation well Permit Application