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Y SAN JUAQUIN 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 I-205 p,PN 239-120-010-000 Property Owner* California Department of Corrections and Rehabilitation Address 9838 Old Placerville Road City/state/Zip Sacramento/CA/95827 Phone 916-255-3359 C-57 Contractor Enprobe Environmental Ilrillinn Services 1 n1 00^ Q Phone Address 9838 Old Placerville Road City/State/Zip Sacr 7 Consultant/Sub-ContractorAEC O M Address 2020 L Street, Suite 400 License# n/a CitylState/Zip Sacramento/CA/95811 Phone 530-589-2019 916-414-5811 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS wwwwwwwwo ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ,rj ft ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2 25 in ❑ MULTIPLE CASINGS C4 MULTI-LEVEL WELL CASING DIA 0.25 In 64 SOILVAPOR PROBE 10 El MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC HCl OTHER ❑ SOIL BORING ® PUSH POINT (GP/ CPT) CONDUCTOR CASING Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 0.4'& 6-13' TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE C4 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs W/-1 through VW -10 GROUT SPECIFICATIONS neat ceinne_nt arnllt DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS_ TREMIE TYPE TO BE USED ENTS: AUGERS n HOSE n PIPE DESTRUCTION METHOD: fCHECKALLTHATAPPLY ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet 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. Signed ; Title/Company Geologlst/AECOM Print Name Jack Rayl Date 12/1/2021 DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: JEFFREY WONG Destruction Inspection By/Dates: Facility/Site Information Date Issued: FA Name Confirmation number: 135441861 SR0084578 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 1 F 209 464-0138 1 Deuel Vocational Institute FA Address 23500 Kasseon FA# FA0016571 PR# PR0524672 FA PE 2960 WP Reviewed By JW Work Plan Date e tember 2021 ❑ C-57 k] C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement Lead Agency Approval MFR COMMENTS/CONDITIONS: Submit a copy of the report/sampling results (no QMR required, SJC Well Standards 13.7.2 When these permanent vapor probes are no longer required/in function, they must just the first sampling be destroyed under separate to EHD per EHD permit WP TYPE wwwwwwwwo PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2901 313 1$152x 5 (max) 760 cc JW 12/6/21 WP0042801 vvww.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application