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SAN JOAQUIN Environmental Health Department 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 2532 Dorset Lane Cross Street Laurelbrook Drive Property Owner* Jian Ming Peng and Tuzhen Li Address 2532 Dorset Lane C-57 Contractor Penecore Drilling City/State/Zip Tracy, CA, 95377 APN 238-300-050 City/State/Zip Tracy, CA, 95377 License# 906899 Phone Phone Phone Address 220 N. East Street City/State/Zip Woodland,CA, 95776 Consultant/Sub-Contractor Arcadis US. Inc. License# N/A Phone Address 735 Tank Farm Road Suite 150 City/State/Zip San Luis Obispo, CA, 93401 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits N/A N/A 530.661.3600 805.459.2391 TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10.0 BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE In ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ]1 SOILVAPOR PROBE—❑ MUD ROTARY CASING THICKNESS 0,2b TYPE OF CASING: ❑ STEEL ❑ PVC R1 OTHER Teflon lubing ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge. Ozone) ® HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 0 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs R-1 F ni ial Npstarl Snit \/arnr PrnhpGROUT SPECIFICATIONS Neat Cement Grout DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS_ TREMIE TYPE TO BE USED COMMENTS: Signed Print Name AUGERS ❑HOSE ❑PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP El feet below surface or feet below surface if >3 feet I hereby certify that I am authorized to complete this application and that the work will be done in accordance with ,� �an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Title/Company Project Manager, Arcadis US. Inc. Christine Perez Date 01/10/2022 Application Accepted By: Grout Inspection By/Dates: � Destruction Inspection By/Dates: Facilitv/Site Information DEPARTMENT USE ONLY JEFFREY WONG Date Issued: 1/25/2022 FA Name CHEVRON SURLAND FA Address 2532 DORSET FA# FA0007884 PR# PR0508012 FA PE 2960 WP Reviewed By J1/�/ Work Plan Date g/30/2021 ElC-57C-57 Authorization for Other to Sign Permit ElWorker's Comp ❑ Worker's Comp Waiver ElEncroachment Permit ElAccess Agreement ElLead Agency Approval 1 MFR COMMENTS/CONDITIONS: Dual nested vapor probe must be completely removed (i.e. overdrill) separate permit. Obtain GPS coordination during inspection: Submit reports/sampling results to EHD per SJC Well Standards 13.7.2 when no longer needed under WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2901 313- 1$152 x 1 608 cc W 1/25/2022 WP0042939 confirmation number: 137884173 SR0084768 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application