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SAN JOAQUIN Environmental Health Department —COUNTY— Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION / NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2J 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 Ication is made in compliance 'lh San Joaquin County Development Title, Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Addres 241-520-01 -000 [/�� r �6EV Ct rl City/State n ca/95337 Phone Cross street l yPt iR.( raOs 0 AP 241-520-01b-000 Property Owner* Oakwood Lake Water District Phone (209) 239-2481 Address PO Box 77980 City/state/Zp Stockton/CA/95267 C-57 Contractor Gulf Shore Construction Services, Inc. License# 964224 J�,Xf 9713 I 25 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/state/zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/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(Vapor/Water) ❑ HAMMERIDRNEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONWCTORCASING ❑Yes []No Boring Dia: Gasing Dia: Casing Depth: ❑ INJECTION lAiSoarce.Dime) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELLISOIL BORING as GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CH ECK ALL THAT APPLY) #WELLS TO BE DESTROYED 4 ❑OVER-BORE DIAMETER of_Inches to depth of feet WELL IDs KW-1 KW-2 KW-3 KW-4 ®PRESSURE GROUT To depth of 21/35 feet below surface ►e GROUT SPECIFICATIONS CquRI-Sp—ecs ❑EXPLOSIVES From to_feel below surface TREMIE TYPE TO BE USED ❑AU ❑H E ®PIP ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMENTS: t(W-1 I) - Sr I � (w R V-vf� 1 -t°b� 1 VO 7 2. o (2MAJ �lt7 C �( 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 Klelnfelder Print Name Joe Ales Data 3/5/2024 DEPARTMENT USE ONLY Application Accepted By: Date Issued: c) Z 4 Grout Inspection By/Dales: (Ifj �� y�f' ' K/1�� 0;Ly1-3J tt/ if Destruction Inspection By/Orates: Facilit /Site Information dil�V7WI Civ i rut.//i ble oc4 L Lsilecd FA Name Oakwood Lake Water District FA Address (2 Ch"L' FA# FA002d401 R# 1 PR0548991 FA PE 6 `r' WP Reviewed By Work Plan Dale ❑G57 C57 Authorizatice for Other to Sign Penh ❑Workers Carp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement OLead Agency Approval MFR COMMEN TS/COND DIIT TIIO NS: Credit Card Payment Confirmation #: 177c9753411 Vo,)tde_ IYV �/S tl� � �[ �C nS C o PSf 7D^J NI:N pr IM I�f` 4r��f D / U lmlQO✓d r� WP TYPE I PIE I SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY I DATE I WELL PERMIT# _ OI`NVOICE# Permit 2902 1 313 $162 x 4 1 $ 648 1 Mi _jW I 2 fSZ w pblt 53 l Cc I7- 341 9*94 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29,01 7-01-2023 Site Mitigation Well Pennit Application �I