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SAN JOAQUIN Environmental Health Department <br /> —COUNTY---- <br /> Greatness grows hare. <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 application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 3081 N Tracy Blvd. City/State/Zip Tracy, CA 95376 Phone (415) 617-5791 <br /> Cross Street W Clover Rd. APN 21418041 <br /> Property Owner* Stuart Limited Partnership Phone <br /> Address P.O. 370298 City/State/Zip Las Vegas, NV 89137 <br /> C-57 Contractor PeneCore Drilling License# Phone (530) 661 -3600 <br /> Address 220 N East St. City/State/Zip Woodland, CA 95776 <br /> Consultant/Sub-Contractor ROUX Associates, Inc. License# Phone (415) 967-6000 <br /> Address 555 12th St. Ste. 250 City/State/Zip Oakland, CA 94607 <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 40 ft ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) [3& HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 in ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA <br /> —Z] SOIL VAPOR PROBE-- _=--=- - ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER <br /> I4 SOIL BORING 2 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparqe,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Q'Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL <br /> rBORING ID 4— <br /> s See site Ian in work Ian GROUT SPECIFICATIONS ;�� <br /> DESTRUCTION WORK TO BE PERFORMED: 1'`� P <br /> IVI07XJ� DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED // ❑ OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ 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 /> j <br /> San xofq7in County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed' �i1G Title/Company Principal Geologist/ Roux Associates Inc. <br /> Print Name Richard Maxwell Date November 29, 2022 <br /> EPARTMENT USE ONLY <br /> Application Accepted By: . Date Issued: f / <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information C lr-%r i' Lle t /0Cq-6XA'- C�— -t 9 �"L c�✓' L.je S <br /> _ r <br /> FA Name , r �� FA AddressO� IrGt�\ FA# D L PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑47 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement Lead Agency Approval FIR <br /> COMMENTS/CONDITIONS: <br /> ✓�'IGn1/ `��,��, vJ G fj C���C r 1 � tor'(- /01. a re tD <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit �G Q5 ( $ x �j 7 � �J 00 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />