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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> IFOPINNV'/ 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 ap�2-4­ <br /> ation 's @,n compliance with San Joaquin ounty evelopm nt Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Addres1-520-17b-000 1} �q (p n I G� <br /> T' l�e' ` city/State/zip Manteca/95337 Phone <br /> Cross Street C IcLya l' : APN 241-520-17A-000 <br /> Property Owner• Oakwood Lake Water District �— Phone (209) 239-2481 <br /> Address PO Box 77980 City/State/zip Stockton/CA/95267 <br /> c-57 contractor Gulf Shore Construction Services, Inc. License# 964224 RPf $J0 /25 Phone (916) 939-4117 <br /> Address 3362 Fitzgerald Rd. city/Statelzip Rancho Cordova/CA/95742 <br /> Consultant/Sub-Contractor Kleinfelder License# Phone (916) 366-1701 <br /> Address 3130 Kilgore Rd, Suite 200 city/State/zip Rancho Cordova, CA 95670 <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 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VowMater) ❑ HAMMERIDRNEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING [I Yes [I No Bourg Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION lAiSoarae.Oxme1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nolo:Maximum Freeful Depth Is 30 Ft) <br /> WELV SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETE Inches to depth of feet <br /> WELL IDsMW-1 ®PRESSURE GROUT To de f30 feet below surface <br /> P <br /> GROUT SPECIFICATIONS Cou pets PRESSURE <br /> From to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSVM PIE ®MUSHROOM CAP ®3 feet below surface or feet 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 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: — ice q <br /> Destruction Inspection By/Dates: <br /> Facilil /Site Information <br /> FA Name akwood Lake Water District FAAddrass © OA :i D FA# A0028101 PR# PRO548991 <br /> FA PE OF( WP Reviewed By I Work Plan Date S Zp 2 <br /> ❑C57 V,57 Authorization for Other to Sign Permit ❑Worke(s Gomp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreememl yLudAgencyApproval VFR <br /> COMMENTS/CONDITIONS: Credit Card Payment Confirmation At: 1/7�7975341 1 <br /> provii� re-`�'- to of F2�S � �U Si Cam/ � IS�i✓1 or uhfil grow1 Vic) Ioyl�c rdro s <br /> WP TYPE PE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY I DATE I WELL PER IT# INVOICE# <br /> Permit 2902 1 313 $162x 1 $ 162 1 C L �� t 7p71� ��0 () <br /> CC W 1 *7+9753ll} 1 S1Cpo g L{ <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 2e-01 7-01-2023 Site Mitigation Well Permit Application <br />