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SAN JOA IN <br />COUNTY <br />\`c9OFoa?%P Greatness grows here. <br />Environmental Health Department <br />SITE MITIGATION WELL Ot 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 23500 Kasson Road, Tracy, CA City/State/Zip 95304 <br />Cross Street <br />Property Owner* <br />Vocational Institution <br />APN 23912001 <br />Address 9838 Old Placerville Road Suite B City/Statelzip <br />Sacramento, CA 95827 <br />C-57 Contractor ENPROBE Environmental direct push drilling services License# 1012248 <br />Address P.O. Box 6093 City/Statelzip Oroville, California 95966 <br />Consultant/Sub-Contractor AECOM TECHNICAL SERVICES INC License# <br />Address 2020 L Street Suite 300 Sacramento City/State/Zip <br />CA 95818 <br />Phone 916-255-3359 <br />Phone 916-255-3359 <br />Phone 530-693-0219 <br />Phone +1-916-216-6125 <br />CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />NUMBER <br />❑ MONITORING ❑ <br />EXTRACTION (Vapor/Water) El <br />lSOILVAPORPROBE El <br />lSOILBORING I-] <br />lINJECTION (Airsuarae, Ozone) El <br />lOTHER El <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH ❑ 80LTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMER/DRIVEN DIA. OF BOREHOLE ElMULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: ElSTEEL El PVC ElOTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING ElYes ElNo Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ElHOSE ElPIPE <br />OTHER: GROUT SEAL PUMPED? ElYes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />W <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED 8 ®OVER -BORE DIAMETER of 8 inches to depth of 20 feet <br />WELLIDs MW -1, MW -1R, MW -2, MW -3, MW -4, MW -5, MW -6 and MW -7F-1 GROUT Todepthof feet below surface <br />GROUT SPECIFICATIONS 95% Portland cement 5% bentonite F-1 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED F1 AUGERS [_1 HOSE ® PIPE ❑ MUSHROOM CAP El feet below surface or feet below surface if >3 feet <br />MENTS: AECOM TECHNICAL SERVICES INC <br />(FORMER URS) <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Rodriguez Sara�anz�.�un;Gy�Clydinance Codes and Standards, and all other applicable California laws. <br />Signed Santiago, <br />hi <br />W�� <br />u oESMAD uezSantlago,Nberto, "" w ATitle/Company AECOM TECHNICAL SERVICES INC <br />Print Name hir 10 ROt YffiJff2'§OAT T I A G 0 Date 07/11/22 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facilitv/Site Information <br />Nom : n������ ►-� <br />FA Name <br />.-. ;r►M4-(-1r/l 6 5 3 N 'b 2, 1 S RCb 2� <br />95205 T g2946&3420 F 209n4�6�4-0138 vvww.sjceh corn <br />1868 E. Hazelton Avenue � Stoc ton CaI`Ifornia � I 1 <br />EHD 29-0104-04-07 Ott d.4- S r q �VQ.. I�1/j� Site Mitigation Well Permit Application <br />�Q.� <br />/ <br />0�(j-�r <br />FA PE <br />WP Reviewed By <br />Work Plan Date <br />❑ C-57 <br />C-57 Authorization for Other to Sign Permit <br />❑ Workers Comp ❑ <br />Workers Comp <br />Waiver❑ Encroachment <br />Permit El Access Agreement [)CLgad Agency Approval <br />FR <br />COMME TS/ <br />d'r' <br />�b+t <br />NDITIONS: jer y �� <br />-�U&L kb%f <br />4A 6 <br />_ _ f uj I <br />or""O�C' <br />S <br />AT <br />` c <br />(/c0 � <br />Se- -fo <br />� <br />6 <br />�� v�1 S Q11 pAe� <br />tes abar�{=�i�i1, ;�v <br />c t10 144 . <br />WP TYPE <br />PE <br />SC <br />I FEE INFO <br />AMT�R]EMITTED <br />CHIECK# <br />I RECV'D_P <br />I <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit`2 <br />) <br />� ; <br />�r <br />VG <br />� <br />lr ZZ <br />Lv� 00 it'35 0 <br />