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SANsJOAQUIN 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 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. This app?cation Is made In compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 241-520-010-000 jcity/statelzip Manteca/95337 Phone Cross Street O` � I gOSD APN241-520-010-000 Property owner* Oakwood Lake Water District Phone (209) 239-2481 Address PO Box 77980 City/slate/zip Stockton/CA/95267 C-57 contractor Gulf Shore Construction Services, Inc. License# 964224 'PP S 3' 1&5 Phone (916) 939-4117 Address 3362 Fitzgerald Rd. City/Statelzip Rancho Cordova/CA/95742 Consultant/Sub-Contractor Kleinfelder License# Phone (916) 366-1701 Address 3130 Kilgore Rd, Suite 200 City/Statelzlp Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLISORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaparrWaler) ❑ HAMMERDRNEN DM OF BOREHOLE ❑MULTIPLE CASINGS MULTREVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL El PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(At Seems.azmel ❑ HAND AUGER GROUT SEAL DEPTN TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER inches to depth of_feet WELL IDs MW-7 ®PRESSUREGROUT Todep of32 feet below surface GROUT SPECIFICATIONS Co peas eo. [I EXPLOSIVES From _feet below surface TREMIE TYPE TO BE USED [I AUGERS ❑HO ®PIP ®MUSHROOM CAP ®3 ow surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done 1n accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed yJ/Gl Title/Company Kleinfelder Print Name Joe Zilles Date 3/5/2024 ` DEPARTMENT USE ONLY Application Accepted By: tW`--' Date Issued: `--� �2� / Q C...7 Grout Inspection By/Dates: Destruction Inspection Ell Facilit /Site Information FAName Oakwood Lake Water District FA Address ! p I FA# I FA0028101 PR# R 1 054899 FA PE I 2 WP Reviewed By v\) I Work Plan Date Z,o z- ❑C-57 C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp WaNer ❑Encroachment Permit ❑Access Agreement VleadAgemyApproval VMFR COMMENTSICONDITIONS: Credit Card Payment Confirmation #: 177975341 FO�tc1z ',12S5u1¢ �o aaSf' 3O Si 4Por > 115 to,Y' O/ UYY-�, ��uf na �sT1J � jWPTYPEj PE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECV-D BY I DATE I WELL PERMIT# INVOICE# Permit 2902 313 $162 x1 1 $ 162 vJ 3 1 Mwa 1 V460f 5 3 �3 11 CCU (?X7A3 5- 3 +k 5F' oo07-B'f 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 7-07-M3 Site Mitigation Well Permit Applkation