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AN.JUAUUIN COUNTY Greatness grows here. 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 23500 Kasson Rd City/State/Zip Tracy/CA/95304 Phone 209-535-4141 Cross Street 1-205 APN 239-120-010-000 Property Owner* California Department of Corrections and Rehabilitation Address 9838 Old Placerville Road Sacramento/CA/95827 C -s7 Contractor En probe Environmental Drillin Address P.O. Box 6093 Consultant/Sub-Contractor AECOM ense# n/a Address 2020 L Street, Suite 400 City/State/Zip ServlCeS License# 1012248 (' ity/state/zip Oroville/CA/95966 Lic city/state/zip Sacramento/CA/95811 Phone 916-255-3359 Phone 530-589-2019 Phone 916-414-5811 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ElEXTRACTION (Vapor/Water) E:1HAMMER/DRIVEN DIA. OF BOREHOLE El MULTIPLE CASINGS E]MULTI-LEVELWELL CASING DIA ❑ SOIL VAPOR PROBE El MUD ROTARY CASING THICKNESS n a TYPE OF CASING: El STEEL El PVC El OTHER X SOIL BORING �_® PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes W No Boring Dia: Casing Dia: Casing Depth: El INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 20 TREMIE TYPE TO BE USED: El AUGERS ❑ HOSE X1 PIPE El OTHER ❑ OTHER: GROUT SEAL PUMPED? El Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs � 1 GROUT SPECIFICATIONS neat rpmpnt arnl`It (MUST BE TREMIED IF GW IS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER -BORE DIAMETER of inches to depth of feet WELL IDs El PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS [:1 EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS [:1 HOSE ❑ PIPE El MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: SB -1 will be grouted after reaching TD. Grout will be filled from the bottom of the boring to 3' bgs, topped off with native soil, and completed to match existing surface conditions. SB -1 location TB[ I hereby cert ify 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. Signed Title/Company Geolog ist/AECOM Print Name J ark R ay I Date 12/1 /2 02 1 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information JEFFREY WnNG DEPARTMENT USE ONLY 12/6/2021 FA Name Deuel Vocational Institute FA Address 23500 Kasseon FA# FA0016571 PR# PR0524672 FA PE 2960 WP Reviewed By JW Work Plan Date September 2021 ElC-57 ®C-57 Authorization for Other to Sign Permit El Worker's Comp El Workers Comp Waiver EJ Encroachment Permit El Access Agreement Lead Agency Approval ® MFR COMM ENTS/CONDITIONS: Submit a copy of the report/sampling results SJC Well Standards 13.7.2 (-10 M �,.n,-., (no QMR required, just the first sampling to /'iii EHD per WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2905 313 $152 X 1 152 cc JW 12/6/21 WP0042800 Confirmation number: 135441861 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F EHD 29-01 06-28-21 SR0084578 209 464-0138 � vvww.sjgov.org/ehd Site Mitigation Well Permit Application