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t SAN JOAQUIN Environmental Health Department <br />------COUNTY----- <br />,q<rFn�','' Greni:ni-ss grov.,s here. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 953-7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 2355 WEST GRANT LINE ROAD <br />Cross Street JOE POMBO PARKWAY <br />Property Owner" TRACY ORCHARD PLAZA LP/ MICHAEL BOGETTI <br />Address 635 MCCRACKEN ROAD <br />C-57 Contractor PeneCore Drilling, Inc. <br />Address 222 North East Street <br />ConsultantfSub-Contractor TERRACON CONSULTANTS, INC <br />Address 902 INDUSTRIAL WAY <br />City/State/Zip TRACY, CA 95377 Phone <br />AP N 21402033 <br />Phone <br />City/State/Zip VERNALIS, CA 95385 <br />License# 906899 <br />City/State/Zip Woodland, CA 95776 <br />License# <br />City/StatelZip LODI, CA 95240 <br />Phone 530-661-3600 <br />Phone 209-367-3701 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5' AND 15' ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />❑ EXTRACTION (Vaper/Water) N HAMMER(DRIVEN DIA. OF BOREHOLE 3" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />Do SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />DO SOIL BORING 6 ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Spa -aa, oz— ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 FI) <br />WELL/ SOIL BORING IDs TSW1, TSW2, TSW3, TSW4, TSW5, GROUT SPECIFICATIONS <br />TSW6, SVP1, SVP2, SVP3 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feel below surface or feet below surface if >3 feet <br />COMMENTS: See attached <br />I herehv certifv that I am authorized to comolete this aoolication and that the work will be done In accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed' k3itlelcompany PROFESSIONAL GEOLOGIST / TERRACON CONSULTANTS, INC. <br />Print Name TONY MIKACICH lr I_j eDate, SEPTEMBER 22f 2021 4� <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />G onilif..IC ifn Infnrm �}inn <br />Date Issued: I © � I /,-,;,A 2-1 <br />FA Name D Q <br />FA Address A# Q 0 z 0 PR# 2 <br />FA PE S <br />WP Reviewed By Work Plan Date <br />❑ C-57 ❑ G57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: � � 1 (� ry a�� � � „ <br />WP TYPE <br />I PE <br />I SC <br />FEE INFO <br />AMT REMiTr.EDI <br />CHECK# <br />I RECV'D BY <br />I DATE <br />I WELL PERMIT# <br />INVOICE# <br />Permit <br />I 2_` 0 <br />+ 3 <br />$152 X <br />C� <br />q IZ41L1 <br />I Wf 00 V <br />C 6y'\� 7 `r' K a K�rv� �, , j. Z10 -t-- <br />1868 E. Hazelton Avenue I Stockton, Califbrnla 5 T 210394Z68 -342071F 209 464-0138 1 www.sjgov.org/ehd <br />EHD 29-0106-28-21 Site Mitigation Well Permit Application <br />-q <br />