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/ S A N J Q A Q U I N Environmental Health Department —C O U N T Y---- 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-57Contractor PeneCore Drilling License# �� (, �, C (C'f 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 ONSTRUCTION WORK TO E PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits I TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ft ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE { ❑ EXTRACTION(VaporMater) C4 HAMMERORIVEN DIA.OF BOREHOLE 2.25 in ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA KI SOILVAPORPROBE 1 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL ❑ PVC ❑ OTHER ' ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑ Yes ❑ No Boring Die: Casing Dia: Casing Depth: ❑ INJECTION(AwSoame.ozonel ❑ HANDAUGER 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) WELL/SOIL BORING IDs See site plan in work plan GROUT SPECIFICATIONS 1 DESTRUCTION WORK TO BE PERFORMED: ( " �r1�'= DESTRUCTION METHOD: (CHECK ALL THATAPPLYI #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 feel below surface if>3 feet COMMENTS: I hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with S n ,op in County Ordinance Codes and Standards, and all other applicable California laws. Signed �,� ,✓iJG L Title/Company Principal Geologist / Roux Associates Inc. Print Name Richard Maxwell Date December 6, 2022 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: — 2 Destruction Inspection By/Dates: Facilit /Site Information /? 5 ('C'C ��'!' v i�E' ✓/ = l%C �l�i c`� ca' (LC' L o—/ L/ :Ip vv S FA Name J Y a (_ _I'S FA Address FA# C .7 _- C PR# y - y'L FA PE 2 C WP Reviewed By Work Plan Date ❑C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑ Encroachment Permit ❑Access Agreement ad Agency Approval MFR COMMENTS/CONDITIONS: �� .�. >✓V � {" f V_ Ord V\l n 0 (tr7\ C' Q t, ✓( c V-1,11 WP TYPE PE SC FEE INFO AMT REMI ED CHECK# RECV-D BY I DATE I WELL PERMIT# INVOICE# / Permit L C, (�� $,� x I z /I �j i ��C i fl t -� 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 vwwv.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application