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2 <br /> SAN J OAQU I N Environmental Health Department <br /> �TCOUNTY— <br /> �"�C�Foii`a�j hrr,.l,..�t� nr'rP.•C �.,,, <br /> SITE MITIGATION WELL & 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 601 North Central Avenue City/State/Zip Tracy, CA 95376 Phone 909-206-9177 <br /> Cross Street East 6th Street APN 235-069-09,-10,-11,-12,-13,-15,and-16 <br /> Property Owner" CRP Affordable Housing and Community Development Phone 909-206-9177 <br /> Address 4455 Morena Boulevard, Suite 107 City/State/Zip San Diego, CA 92117 <br /> C-57 Contractor Environmental Control Associates, Inc. License# 695970 Phone 831-662-8178 <br /> Address 3011 Twin Palm Drive City/State/Zip Aptos, CA 95003 <br /> Consultant/Sub-Contractor Partner Engineering and Science, Inc. License# Phone 916-405-1275 <br /> Address 1512 Eureka Road, Suite 205 City/State/Zip Roseville, CA 95661 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15.5 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ® HAMMER/DRIVEN DIA.OF BOREHOLE 2.25-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ROBE 5 TYPE OF[I SOIL BOR NG ❑ PUSH OINT(GPI CPT) CONDUCTOR CASING El Yes i, CASING:No Boring D a [ISTEE_Casing D a: Casing OTHER ",jy}r D,Dept t/,� a� <br /> ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH (j,V TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE S�iw VNY <br /> ❑ OTHER ❑ OTHER:— _ GROUT SEAL PUMPED? Sd0 te:Maximum Freefall Depth is 30 Ft) <br /> WELL]SOIL BORING IDs B64 B7, B8, B9^and B10 GROUTSPECIFICATIO N a Cement r <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: �lu tr f► L-G-e �VL4. wl <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed L' Title/Company Partner Engineering and Science, Inc. <br /> Print Name Cory Martini Date 9/25/2025 <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By: Date Issued: ` Z('� Z <br /> Grout Inspection By/Dates: on <br /> Destruction Inspection By/Dates: 0 1 ]7" 5 OrQ <br /> Facili /Site KkALS IQSS ) <br /> FA Name O t �, l FA Address V R V4L l FA# Ub Z U) PR# J <br /> FA PE WP Reviewed By Work Plan Date <br /> W57 -57 Authorization for Other to Sign Permit Workers Comp ❑Worker's Coml Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval'o MFR <br /> COMMENTS/CONDITIONS: 5\ l �J . 1 Q'S _ i �� ( _ LC-0 i <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RE V'D BY DATE WELL PERMIT# INVOICE# <br /> Permit JA D E -�13 $179 x Sr 0,0 ' -t6b W Pa 5 0117 5 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2M1 07-01-2025 Site Mitigation Well Permit Application <br />