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4 <br />,r�lrPld . <br />SAN JOACMIN <br />--COUNTY <br />Greatness grows hem. <br />�r1vo��or�rr�enta8 0000 n D) � ��������� <br />SITE MlTIGATION VVt:LL di� bumilUG Pam1vi1i ArI�L1%.#1A �9 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />21'.. Flours Advance Notice Required For All Inspections <br />CALL (209) 0537097 For INSPECTIONS <br />cation is hereby made to San Joaquin County for a permit to construct and/or install the work described <br />Appli. <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 I-580 EB/Corral Hollow Rd Exit Ram <br />/CA/95377 Phone <br />Cross Street Tracy Hills Dr <br />Property Owner* ICGC, LLC <br />Address 24 West 10th St <br />C-57 Contractor Cascade Drillin <br />Address 3459 Collins Ave <br />Consultant/Sub-Contractor Hale & Aldrich, Inc. <br />Address 2033 H Main St, Suite 309 <br />CitylstatelZip Tracy <br />APN 251-060-080-000 <br />CitylstateJzip Tracy/CA/95376 <br />Phone <br />License# 1058336 <br />Richmond/CA/94806 <br />ense# <br />/State/Zip Walnut Creek/CA/94596 <br />Phone <br />City/Statelzip <br />Lic510-478-0858 <br />Phone 714-371-1805 <br />CONSTRUCTION WORK TO BE PERFORMED: '`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (VaporlWater) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 3.25 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE 5 ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />6�l SOIL BORING 5 IZ) PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes [RI No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air sparge, Ozone) R HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes N No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs _ B-8 to B-12 (see Figure 2 in GROUT SPECIFICATIONS <br />Work Plan) <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED 5 ❑OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs B 8 to B-12 ❑ PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS Bentonite [] EXPLOSIVES__ From to feet below surface <br />TREMIE TYPE TO BE USED El AUGERS [:1 HOSE [jCA <br />PIPE Who [] MUSHROOM P ❑ Mbit below surface or feet below surface if>3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application 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 Title/Company Senior Project Manager/Haley &Aldrich, Inc. <br />Print Name Jason Gra:nn:t:::: Date 12/8/21 <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issued: Z� <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: ' Zb <br />tFAName <br />t /Site <br />Information C <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464! 1 � www.sj <br />L � <br />FA Address <br />FA# <br />�' <br />� PR# (� <br />FA PE <br />WP Reviewed By <br />Work Plan <br />Date 2 1 <br />[:1C-57 Authorization <br />for Other to Sign Permit <br />ElWorker's Comp El Workers Comp <br />Waiver ElEncroachment Permit <br />ElAccess Agreement <br />ElLead Agency Approval 4MFR <br />COMMENTS/C NDITIONS: <br />� , J <br />r d r—� <br />d <br />.H P <br />py <br />V'/e ` ('4 <br />dq, s <br />PE SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />ELL <br />PERMIT#7 <br />INVOICE# <br />WP TYPE <br />�- <br />$152 x <br />`� <br />p <br />1 <br />Di% <br />l� <br />Permit <br />6 W <br />gov.org/elid <br />EHD 29-01 06-2f3-21 <br />Site Mitigation Well Permit Application <br />