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SAN JOAQUIN Environmental Health Department --COUNTY-- Greatness gro► y , here. 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 3081 N Tracy Blvd. City/State/Zip Tracy, CA 95376 Phone (415) 617-5791 Cross Street W Clover Rd. APN 21418041 Property Owner* Stuart Limited Partnership Phone Address P.O. 370298 City/State/Zip Las Vegas, NV 89137 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 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 40 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 5 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER C4 SOIL BORING 2 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ElINJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? E]%Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) , WELUSOILB RING IDs See site plan in work plan GROUT SPECIFICATIONS ;' �►1 DESTRUCTION WORK TO BE PERFORMED: �`/ Pv1� 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 S n q in County Ordinance Codes and Standards, and all other applicable California laws. 9 fG"'G7- p Y p 9 Signed ;� � Title/Company an Principal Geologist/ Roux Associates Inc. Print Name Riche d Maxwell Date November 29, 2022 EPARTMENT USE ONLY Application Accepted By: Date Issued: (-J Grout Inspection By/Dates: �d '' h !�J /C L f 1 !�22 Destruction Inspection By/Dates: Facilit /Site Information jjA,5,XCy r �' 1.7� � t` Q l� V cX- 0f �L S FA Name r ),r FA Address Q FA# I C) oll PR# 6 FA PE WP Reviewed By Work Plan Date Itol6l,2 C� ❑C-57 ❑,457 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ElLead Agency Approval FR COMMENTS/CONDITIONS: / l'` �c Y` as -�i�uPo r-ra �G�YI/7Gj/i vL' 4'J L`j ��SL 1' CtC Vt 6-C G ��--/ �y G�K b i'� 'j� , 1+1�) r C,1:4jj .1 A 1 it , 1 In" wo r .1I n �G14 WP TYPE PE Sc FEE INFO AMT REMITTED CHECK#' I RECV'D BY DATE WELL PERMIT# INVOICE# Permit �L" �� ` 13 $ x 3 ) 74 ,.J Vr I Z 1 V oo T-; 1 S jZpC) 10 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application