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CJFXAIJlf�t r SAN JUAQUIN Greatness grotivs here. NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A. Hours Advance Notice Required For All Inspections CALL (200) 9537697 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 3250 West Grant Line Road, City/State/Zip Tracy, CA 95377 Phone 209-830-5340 Cross Street SR 205 and Byron Road Property Owner* Costco Wholesale Corporation Address 1101 Second Avenue, Suite 100 C-57 Contractor Cascade Drilling, LP 3459 Collins Ave. Consultant/Sub-Contractor Kleinfelder Address 380 North 1st Street APN 238-600-060-000 Phone 209-962-6611 City/State/Zip Seattle, WA 98101 License# CA C-6# 1058336 Phone 510-478-0858 City/State/Zip Richmond, CA 94806 License# PG# 5925 Phone 510-409-8599 City/State/Zip Sari Jose, CA 95112 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 10 feet and 20 feet❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ElEXTRACTION (VaporMater) ElHAMMER(DRIVEN DIA. OF BOREHOLE 2,25 inch diameter ElMULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA [I SOILVAPORPROBE ElMUD ROTARY CASING THICKNESS NA TYPE OF CASING: ElSTEEL ElPVC ❑ OTHER ® SOIL BORING All borings ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ElYes ElNo Boring Dia: Casing Dia: Casing Depth: ElINJECTION (Air sparge, Ozone) [1HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS E3HOSE ElPIPE ElOTHER ❑ OTHER: GROUT SEAL PUMPED? [IYes ® No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs SB -1 through SB -8 GROUT SPECIFICATIONS 2 to 20 feet and 6 to 10 feet DESTRUCTION WORK TO BE PERFORMED: 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 ❑AUGERS ❑HOSE ❑PIPE ❑ MUSHROOM CAP El3 feet below surface or feet below surface if >3 feet bentonite mixture will be used to grout the borings from the bottom up #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED COMMENTS: Portland cement 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. Print Name: Richard Alcartado Title/Company _ Date: 12/1412021 Estimator/Cascade Application Accepted By:_ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name fOSTCO JEFFREY WONG Date Issued: 12121 /2021 FA PE confirmation number 136283722 SR0084633 1868 E. Hazelton Avenue � Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation WAREHOUSE AND GAS 2950 STATION 658 FA Address 3250 W GRANT LINE FA# WP Reviewed By J�/�/ FA0021728 PR# Work Plan Date 12/17/2021 PR0537704 C-57 ❑ C-57 Aulttorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval IN MFR COMMENTS/CONDITIONS: SUBMIT A COPY OF THE REPORT TO EHD Qwong@sjgov.org) ro v d w16 j > >ea V.) c eta t'c� mwu�ly ins ^ t vt>v R per SJC WELL STANDARDS � �► �c p� ��t r� 13.7.2 (cx c� i hCJGr WP TYPE - -- PE SC FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# - INVOICE# Permit 2905 313 $152 x 3 456 CC JW 012/20/21 WP0042854 Well Permit Application