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SAN �JOAQUIN p �, Environmental Health Department —COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections j 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. is application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Addres 241-520-01 -000 368I C414\[°lyi City/State 'u. anteca/95337 Phone Cross Street R I V Pt J/—' (2 0,C10 AP 241-520-01 -000 Property Owner- Oakwood Lake Water District Phone (209) 239-2481 Address PO Box 77980 City/State/Zip Stockton/CA/95267 C-57 contractor Gulf Shore Construction Services, Inc. License# 964224 i*r D/a I A Phone (916) 939-4117 Address 3362 Fitzgerald Rd. City/State/Zip Rancho Cordova/CA/95742 Consultant/Sub-ContractorKleinfelder License# Phone (916) 366-1701 Address 3130 Kilgore Rd, Suite 200 City/State/zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite aorings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring oa: Gasing Dim: Casing Depth: ❑ INJECTION fPirSwrae.Ozmel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS 1 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 [1 OVER-BORE DIAMETER of_inches to depth of feet WELL IDs MW-2 MW-3 MW-4 ®PRESSURE GROUT To depth of 28/33 feet below surface 3kz — GROUT SPECIFICATIONS Couaty-6pecs ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED [I AUGERS ❑HO ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet balmy surface if>3 feet COMMENTS: rA" 2 - S 1 . -52 IC I"Le w4-3 - 2-8 .G2 kAW 33 - 53 rL I 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 9v�� Tine/company Kleinfelder Print Name Joe Zilles Date 3/5/2024 EPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: ll4- CImcvzk0 ( w L.y Destruction Inspection By/Dates: Facilit /Site Information FA Name akwood Lake Water District FAAddress Q ex $ FA# FA0028101 PR# PR0548991 FA PE b WP Reviewed By I Work Plan Date ,) Zp Z ❑C-57 C57 Authorization forOlher to Sign Permit ❑Workees Camp ❑Workers Cor Waiver ❑Enaoachmenl Permit ❑Access Agreement VeadAgenGyApproval MFR COMMENTSICONDITIONS: Credit Card �nv d e PreSy'A� E� Payment Conff'' tio #: 177975341 L t G a4' letts Z i � 15'Mir' or L ,pr�Lrr VIP TYPE I PE I SC I FEE INFO JAMT REMITTED1 CHECK# RECV-D BY I DATE WELL PERMIT# INVOICE# Permit 2902 1 313 $16213 $ 486 C 131, Z ZD wPnoLrs365 Am nfll�°! 344 .59DO8- 84to 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-O f38 I www.sjcehd.com EHD 29-01 7-01-2023 Site Mitigation Well Pamir Application