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S A N J O A Q U I N Environmental Health Department —COUNTY-- . Grr.nt.r;ess yrtl>vs ftcr'r-. 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 Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 812 Clover Rd City/State/zip Tracy, CA 95376 Phone (415) 617-5791 Cross Street Orchard APN 21418024 Property Owner* Orchard Estates Mobile Home Park Phone Address 812 Clover Rd Clty/State/zlpTracy,/QA 95376 C-57 Contractor PeneCOre Drillinq License# C ( �i p ' �(' ( Phone (530) 661 -3600 Address 220 N East St. City/State/zlp Woodland, CA 95776 Consultant/Sub-Contractor ROUX Associates, Inc. License# Phone (415) 967-6000 Address 555 12th St. Ste. 250 City/state/zip Oakland, CA 94607 CONSTRUCTION WORK TO BE PERFORMEDLLATION Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits 1(YPE OF WELLIBORING NUMBER INSTA YP CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 It ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE �1 ❑ EXTRACTION(Vapor/Water)) IN HAMMERIDRIVEN DIA.OF BOREHOLE 2.25 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ® SOILVAPOR PROBE 2 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Ole: Casing Dia: Casing Depth: ❑ INJECTION(Airsoaree.ozone/ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑ No (Note:Maximum Freefall Depth Is 30 Ft) I WELL/SOIL BORING IDs See site plan in work plan GROUT SPECIFICATIONS l t•Off 4' 1) (� �� /,.� ( 1� l' f" IbIC:.;� t- .,t1 DESTRUCTION WORK TO BE PERFORMED: �<DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: hereby certify that I am authorized to complete this application and that the work will be done In accordance with In County Ordinance Codes and Standards, and all other applicable California laws. Signed�%� �ifG L� Title/Company Principal Geologist / Roux Associates Inc. Print Name Richard Maxwell Date December 6, 2022 DEPARTMENT USE ONLY Application Accepted By: 1, __ - (/ 1 Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: !i Z Facilit /Site Information FA Name = _ FA Address j�� ( " �1 (� FA# Cl( ' c-�� L� PR# ; S r FA PE el Reviewed By \} Work Plan Date (; L, () ❑ C-57 C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement PLead Agency Approval ' MFR COMMENTS/C N ITIONS:WP TYPE I PE SC FEE INFO JAMT REMITTED CHECK# I RECV'D BY DATE WELL P RMIT# INVOICE# Permit �tV' i & MYCO411311 . 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464- www.sjcehd.com EHD 29.01 04-04-07 Site Mitigation Well Pernit Application