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SANcJOAQUIN 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) 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 Wtthh San Joaquin County Dev lopment Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 241-540.A+000 3q-0q 00=0 city/State/zip Manteca/95337 Phone <br /> Cross Street fti LAc}Q AP N 241-540-14b-000 <br /> Property Owner* Lakeview Shores Inc. Phone <br /> Address 1463 Moffat Blvd. Suite 7 City/State/zip Manteca/CA/95336 <br /> C-57 contractor Gulf Shore Construction Services, Inc. License# 964224 Me f or / 31 /ZS Phone (916) 939-4117 <br /> Address 3362 Fitzgerald Rd. city/State/zip Rancho Cordova/CA/95742 <br /> Consultant/Sub-Contractor Klelnfelder License# Phone (916) 366-1701 <br /> Address 3130 Kilgore Rd, Suite 200 city/statelzip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringstWelis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapodWater) ❑ HAMMERIDRIVEN CIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING CIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Da: Casing Die: Casing Depth: <br /> ❑ INJECTION(Air Soarae.ozmel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Ma)dmum Freefoll Depth is 30 Ft) <br /> WELLISOIL BORING IDs GROUTSPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER inches to depth of feet <br /> WELL IDS KW-6 ISI PRESSURE GROUT To dep of20 eet below surface <br /> GROUT SPECIFICATIONS COURtISPOGS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS ❑HOS PIPE MUSHROOM CAP 3 feet below surface or feel below surface if>3 feet <br /> COMMENTS: <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 Title/Company Kleinfelder <br /> Print Name Joe Zilles Date 3/5/2024 Application Accepted By: � - DEPARTMENT USE ONLY Date Issued: Z 0 (/ <br /> Z 6 Z- <br /> Grout Inspection By/Dates: r ' -{ � zi <br /> Destruction Inspection By/Dates <br /> Facilit /Site Information <br /> FA Name akwood Lake Water District FAAddress Ifo O $E FA# FA0028101 PR# R0548991 <br /> FA PE S WP Reviewed By Work Plan Dale 3 S <br /> ❑P57 P57Authorizagoo for Other to Sign Pool ❑Workers Camp ❑Workers Comp Waiver ❑Ena0achmenl Pemiit ❑Access Agreement Qfead Agency Approval VMPR <br /> COMM'E�INTSICONDITIONS: Credit Card Payment Confirmation M 177975341 <br /> �faJL� �� Sswte �v k-' Iea� Vpsi -(-6jZ1j5—+gin or NIT�II��ak� ✓lo (oxser dL-a <br /> WP TYPE PE I SC I FEE INFO JAMT REMITTIED1 CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit 2902 313 $162x 1 $ 162 -�f y✓ 3112�2v WFo q J3y+j <br /> CC -WF+- -9� ,5 µI SRo0 Sfib `1 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2M17-01-2023 Site Mitigation Well Permit Application <br />