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SAN J p e, OAQUIN Environmental Health Department —COUNTY— "=lt; Dn,pP� 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 application is made in compliance With San Joaquin County Developmer)t Title, Chapter 9-1116.3,and the San Joaquin County Well Standards. I W, w Job Addres 241-520-21 -000 '7,py 6 W City/State/Zip Manteca/95337 Phone Cross Street !WVAL APN 241-520-210-000 Property Owner* Lafferty Communities Phone (925) 355-1305 Address 5000 Executive Parkway, Suite 350 city/state/Zip San Ramon/CA/94583 c-57 contractor Gulf Shore Construction Services, Inc. License# 964224 W 7/3t 125 Phone (916) 939-4117 Address 3362 Fitzgerald Rd. city/state/zip Rancho Cordova/CA/95742 Consultant/Sub-Contractor Klelnfelder License# Phone (916) 366-1701 Address 3130 Kilgore Rd, Suite 200 city/statelzip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Ofrsite Bodngs/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(VapoMaler) ❑ HAMMERNRNEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI GPT) CONDUCTOR CASING [I Yes [I No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION rAFaoerae.0eme1 ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nola:Mapmum Freefall Depth is 30 Ft) WELUSOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDS KW-5 KW-7 KW-8 ®PRESSURE GROUT To depth of 22/25 feet below surface GROUT SPECIFICATIONS CgpMySpecs At ❑EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS Ll HOS [A PIPE, MUSHROOM CAP ®3 feel below surface or feel below surface if>3 feet COMMENTS: I hereby certify that I 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 Title/Company Kleinfelder Print Name Joe Zilles Data 3/5/2024 ` / D.✓A�RTMENT USE ONLY /2 b /Z0 �T Application Accepted By: ,('� 4�-1 -— 1 Date Issued: , !/ Grout Inspection By/Dales: Destruction Inspection By/Dates: Facilit /Site Information FAName akwood Lake Water District FAAddress C�S I8 Ox FA# IFA0028101 I�JPR# R0548991 1 FA PE WP Reviewed By Work Plan Dale / 5- 2 O Z4� ❑G57 G57Au0anzationfer0lherto Sign Permit ❑Workers Cunp ❑Workers Comp Waiver ❑Encroachment Pem,it ❑AccassAgnaamenl Plod Agency Approval FR COMMENTS/CONDITIONS: Credit Card Payment Confirmation #: 177975341 �huide P�2iff r2 +0 Ot f" Jars(' 30(3 i -For y 15M'IK af- jAnfi( drnkf via laA&Q- -drop WP TYPE I PE SC I FEE INFO JAMT REMITTED CHECK# I RECV'D BY I AT I WELL PERMIT# I INVOICE# Permit 2902 313 $162 x 3 $ 486 -1 (Z 24 I WOO N 3 IK1ftq } 341 S/Loos*-S+ ; 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2MI MI-2023 Site Midgaaon Wall Penntl Appliraaon