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SANJOAQUIN Environmental Health Department <br /> " —COUNTY— <br /> Greatness grows here. <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) 963-7697 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 9-1116.3,and the San Joaquin County Well Standards. <br /> Job Address 9500 West Linne Road City/State/zip Tracy, CA 95377 Phone Not provided <br /> Cross street South MacArthur Drive, Tracy, CA APN 253-120-48 <br /> Property Owner- Teichert Land Corp Phone 916-484-3272 <br /> Address 3500 American River Drive city/stateizip Sacramento, CA 95864 <br /> C-57 Contrac Y Cascade Drilling -' License# 1058336 Phone 707-3783768 <br /> Address 345 GolllmrAvenue" City/State/Zip Richmond, CA 94806 <br /> ConsuitantfSub-contractor Partner Engineering& Science, Inc. License# N/A Phone 774-414-3666 <br /> Address 2154 Torrance Boulevard Cityistate/zip Torrance, CA 90501 (Michel Helou) <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsile BoringsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELLISORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING 1 ID HOLLOW STEM BORINGDEPTH 119 OBOLTEDTRAFFICSOX ❑STOVEPIPE <br /> 0 WRACTION(Vam/Water) ❑ HAMMERrDRIVEN DIA.OF BOREHOLE 4• ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOFCASING: ❑STEEL ❑PVC 0 OTHER <br /> ® SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bering Dia: Casng Ble: Casing Depth: <br /> ❑ INJECTION wswo.ozmal ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPETO BEUSM, [I AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? [I Yes [I No (Nola:Maximum Freew.oe�Is 30 FQ <br /> WELUSOILBORINGIDS Bill GROUTSPECINCATIONS Neat cement rout 1 trek mmie, <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED [I OVER-BORE DIAMETERof_inches to depth of feel <br /> WELL We [I PRESSURE GROUT Todepthof feetbetowsudaw <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES Fran_to_feelbelowsudace <br /> TREMIE TYPE TO BE USED [I AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel belay surface if>3 feet <br /> COMMENTS: No soil vapor sampling <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 -&CI L,�id , Title/Company Project Manager/Partner Engineering & Science, Inc. <br /> PdntNameMichel Helou Date,8/23/2023 <br /> D ART E T USE ONLY n <br /> Application Accepted By: Dale Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dales: <br /> Facilll /Site Information <br /> FA Nema I( FAAddraw PR#s Z <br /> FA PE IMP Reviewed By —tA <br /> J Work Plan Date 2 <br /> 0057 G57Augwrizalbn feroberb Sign Permit ❑Workers Camp OWarkefsco"Welwr ❑Enaoachmenl Pwal ❑Aaessfteemenl ❑LeadAgencyAppawal MFR <br /> COMMENTS/ O ITIONS: ?.Cu1, �Tc I � c'� 23 <br /> ( /' 1. 2 r L �/� <br /> N f F r f 0 f pva n V{J4-1 q' ' t <br /> IWPTYPEI PE I SC I FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE WELL P'E1RA <br /> INVOICE# <br /> Pennil Q 5 $ X .4 l i �/r� I .1 �3 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s / <br /> EHD nee 04-20-23 site Mitigation well PemN Application <br />