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SAN JOAQUIN Environmental Health Department <br /> +1\ COUNTY <br /> P� <br /> `.�1lrova'1.: 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. j <br /> This application is made in Compliance with San Joaquin County Development Title, Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Addres 241-510-0�0-000 Oak,&,d (4. -V)+'e/ 0citystailki Manteca/95337 Phone <br /> Cross Street ✓OI'L Z((,'(� AP 241-510-05I0-000 <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 ! Q 9/1, 2 S Phone(916) 939-4117 <br /> Address 3362 Fitzgerald Rd. city/State/zipRancho Cordova/CA/95742 <br /> Consultant/Sub-ContractorKleinfelder License# Phone (916) 366-1701 I <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 ❑ HOLLOWSTEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(ValexiWater) ❑ HAMMERrDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI OPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION msenee.eLarel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Deg@ is 30 Ft) <br /> WELD SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 Cl OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL Ds MW-5 MW-6 r 1 ®PRESSUREGROUT Todepthof3l/39 feetbelowsurface <br /> GROUT SPECIFICATIONS CoWW-8� ,Qyl - n ❑EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO BE USED [I AUGERS El HOSE ®PIPE ®MUSHROOM CAP 1gl 3 feet below surface or feet below surface if>3 feel <br /> COMMENTS: µ�,f-5 38, 6L ' -IOC_ <br /> Mvu-6 t. � T <br /> I hereby certi hat i am authorizedb toL 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 S Title/Company Kleinfelder <br /> Print Name Joe Zilles ' Date 3/5/2024 <br /> �J DEPARTMENT USE ONLY �7 Ly <br /> Application Accepted By: 1/�L�J Dale Issued: 3 / Ld <br /> Grout Inspection By/Dates: kwul!a! { �( <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name Oakwood Lake Water District FA�VoF, q To FA# FA0028101 I PRN PPRO5489911 <br /> FA PE 2m 65 1 WP Reviewed By �I-v\) I Work Plan Date 3 1 (/Zp''K <br /> ❑C57 G57AINIorizallonfaOtherto Sign Permit ❑Worker's Camp ❑Warkel's Comp Waiver ❑Encroachment Pemmit ❑Access Agreement geadAgencyAlipproval MIR <br /> COMMENTS/CONDITIONS, C edit Card Payment Confirmation #: 177975341 <br /> �4(,� ffO� e2 b w, lezt 2012s1 �r 16-Mirt Qr L4N'el9rvrrf"no � alydPs <br /> WP TYPE I PE SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit 2902 313 162 x 2 $ 324 C �� 131, 00 p`fb 3 g <br /> 1868 E. Hazelton Avenue I Stockton,, Ca ifomid35205 1 T 209 468-3420 1 F 209 464 0138 1 www.sjehd.com <br /> FHD 29-01 7-01-2023 Site Mitigation Well Permit Application <br />