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,- Pauin��' ,,, (� `' °� .:=, �, � � � �q�IFO�•��P: SAN J�AQUIN COUNTY Greatness grows here. Environmental Health Department SITE MITIGATION WELL &BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 Road Cross Street Mancuso Road Property Owner* California Department of Corrections Address 23500 Kasson Rd. City/State/Zip Tracy, CA 95304 Phone 209-835-4141 APN 239-12-001 city/state/zp Tracy, CA 95304 Phone c-s� contractor CASCADE Drilling License# 1058336 Phone 916-638-1169 Address 3000 Duluth Street City/State/Zip Werst Sacramento, CA 95691 Consultant/Sub-Contractor Wood E&IS, InC. License# Phone Address 180 Grand Avenue, Suite 1100 city/state/zip Oakland, CA 94612 510-663-4100 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ❑ MONITORING ❑ ❑ EXTRACTION (Vapor/Water) ❑ ❑ SOIL VAPOR PROBE ❑ SOIL BORING 12 ❑ ❑ INJECTION (Air sparge, ozone) ❑ OTHER ❑ W►W��L.Y�7L�Iil:�1►[Hl� INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH 8 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA. OF BOREHOLE 4 inches ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER PUSH POINT (GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOS ❑PIPE OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (No :Maximum reefall Dept is 30 Ft) GROUT SPECIFICATIONS � ��Q' /..� �,� ,/%'� DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED 12 WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE COMMENTS: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑OVER -BORE DIAMETER of inches to depth of feet j� PRESSURE GROUT To depth of feet below surface o S �,�. ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or _ _ feet below surface if >3 feet 12 soil borings to be hand augered, sampled, and destroyed with cement grount to 3 ft. bgs. 1 hereby certify that 1 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 ASSOCIate Engineer Print Name Harold Rush Date 9/30/2020 •PARTMENT USE ONLY � O �� % Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: ' ' /(��i 7�ZD G� Facility/Site Information FA Name � FA Address �s�a �S V� FA# �' l ,�� PR# �' �� ' FA PE 2�t � WP Reviewed By �� Work Plan Date t Z � � 0 ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Ap rov R 4-1 COMMF�NTS/CONDITIONS:.�r-ad s 1_ .. 1 0. r A � � G �y 1� � � ��,�i 1 i WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit C"W 3 {� $152 x � � �� � ZI � b' 1868 E. Hazelton Avenue � Stockton, Califor�' ,53205 � 09 468-3420 � EHD 29-01 OS -01-17 t o�k3gl�o6 F 209 464-0138 � vvww.sjcehd.com S��ti�ati��.j/y,�ll fe�t(�pkCation J