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- SAN JOAQUIN Environmental Health Department COUNTY 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 City/State/Zip Tracy. CA 95376 C-57 Contractor PeneCore Drilling License# Phone (530) 661-3600 Address 220 N East St. City/State/Zip 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 C A ONSTRUCTION WORK TO BE PE FORMED• *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits �� E OF WELL/BORING NUMBER NSTAI I 'a? N YPE CO RUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ft ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water), HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 in ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 2 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,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) WELD SOIL BORING IDs See site plan in work plan GROUT SPECIFICAT ONS LWC) rmalziz& .5c) DESTRUCTION WORK TO BE PERFORMED: �"�' ( SDESTRU -TION 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: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with S n gzlin County Ordinance Codes and Standards, and all other applicable California laws. Signed �,�, �i� � ,� Title/Company Principal Geologist / Roux Associates Inc. Print Name Richard Maxwell Date December 6, 2022 DEPARTMENT USE ONLY � � � F� rZ Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address + FA PE --v I WP Reviewed By V "i Work Plan Date V (�Z ❑ C-57 [51,C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement Lead Nancy Approval FIR COMMENTS/CQN 1TIONS: �� ' V �(,�� . �� • „ „ �S L � . TV ryll /rnA� to)r r' 5: r ce ru-Q— U49 WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PVRMIT# INVOICE# Permit 0( st $152"� 2 -� 11, 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138CfwWW.j ehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application