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AN JUAW N <br />COUNTY <br />C;rentness grows here, <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Hours Advance Notice Required For All Inspections <br />CALL (209) 953=7697 Dori 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 I-580 EB/Corral Hollow Rd Exit Ram <br />Cross Street Tracy Hills Dr <br />Property Owner* ICGC, LLC <br />CitylStatelZip Tracy/CA/95377 Phone <br />APN <br />Address 24 West 10th St <br />251-060-090-000 <br />Citylstate/Zip Tracy/CA/95376 <br />C-57 Contractor Cascade Drillinq License# 1058336 <br />Address 3459 Collins Ave <br />Consultant/Sub-Contractor Haley & Aldrich, Inc. <br />Address 2033 N Main St, Suite 309 <br />City/State/Zi p <br />License# <br />CitylStatelZip <br />Richmond/CA/94806 <br />Walnut Creek/CA/94596 <br />Phone <br />Phone <br />510-478-0858 <br />Phone 714-371-1805 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsNVells 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 ❑ BOLTEDTRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 3.25 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />LX SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />(� SOIL BORING 1 PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes N No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone) ® HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes j4 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs 13-7 (see Figure 2 in Work GROUT SPECIFICATIONS <br />Plan) <br />DESTRUCTION WORK TO BE PERFORMED.: <br />#WELLS TO BE DESTROYED 1 <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />WELL IDs B-7 <br />GROUT SPECIFICATIONS Bentonite - <br />TREMIE TYPE TO BE USED ElAUGERS ElHOSE ElPIPE <br />COMMENTS: <br />Signed <br />Print Name <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 />❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />I hereby certify that I am authorized to complete this application and that the work will be done in actor ante wi <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Jason Grant <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Gnnili4vlCifn In9nrmoiinn <br />Title/Company Senior Project Manager/Haley &Aldrich, Inc. <br />Date 12/8/21 <br />DEP RTM�NT USE ONLY <br />Date Issued: � � � /> I <br />ly�t} iii- i �4•I <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 64-0138 1 www.sjgov.org/ehd <br />EHD 29-01 06-26-21 Site Mitigation Well Permit Applicati <br />FA Name <br />FA PEv <br />WP Reviewed By <br />Work Plan Date <br />Z <br />Z <br />❑ C-57 7 Authorization for Other to Sign Permit <br />❑ Worker's Comp ❑ Worker's <br />Comp Waiver ❑ <br />Encroachment Permit <br />❑ Access Agreement ❑ Lead Agency Approval D4FR <br />COMM ENTSIC NDITIONS: <br />b,o6)f 19 <br />-� <br />020 1 <br />WP TYPE <br />PE - <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D <br />BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />$152 xvV <br />�D 40? Q0 <br />15 <br />on <br />