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SAN. OAQUIN Environmental Health Department r,6 COUNTY — Greatness grows 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 vvith San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 780 E 6lh Street City/statelzip Tracy, CA 95376 Phone Cross Street N Central Ave. APN 235-15-002 Property Owner` Union Pacific Railroad Company Phone Address 1400 Douglas St. City/State/Zip Omaha, NE 68179 C-57 Contractor Confluence Technical Services License# 1035255 Phone 707-639-7709 Address 800 M Street CltylState2lp Rio Linda, CA 95673 Consultant/Sub-Contractor Antea Group License# Phone 737-279-9848 Address 11010 White Rock Rd City/StatelZip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: OffsHe Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELUEORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5at W.1 at 28 ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) 0 HAMMER/DRIVEN DA OF BOREHOLE 2,375' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIN NA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER NA f] SOILBORING 6 © PUSH POINT(GP/CPT) CONDUCTORCASING [I Yes ©No Boring Dia: NA Casing Dia: NA Casing Depth: NA ❑ INJECTION(0apome.0mnO ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yeesps,,�191 No (Note:Miedim an Freefall De Is 31 Ft) 1`*^� WELOSOIL BORING IDS &1,B-2,B3,B-4,B-5,B-S GROUT SPECIFICATIONS )O ��;.$ 14 r�i tt e r•1 -Y NAB W�� 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 ❑PRESSUREGROUT To depth of feetbelow surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ^� ❑MUUSHROOM1 CAP ❑p3 feet below surface or feet below surface if>3 feet COMMENTS: rr�.. 3 ClV\ 3 C- FL I/v•r� \ wYs I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin Coou�nttyy Ordinance Codes and Standards, and all other applicable California laws. Signed &7:" / N Title/Company President/Confiuence Technical Services,Inc. Print Name Ralph MCGa ey Date o2J21rm24 PARTMENT USE ONLY r-T Application Accepted By: Date Issued: �n [� Grout Inspection By/Dates: _ G Z fT.J Destruction Inspection By/Dates: Facili /Site Information - FA Name up R R 1, FA Address 8 S i�( r A# PR# FA PE 'Z9 6 WP Reviewed By I Work Plan Date 013 12 12 G57 0G57AUaledzaWnfa Othefto Sign Permit ❑Workels Comp ❑Workers Comp Waive( ❑Enc/Irowhoo Permit [1Ac=sAg,eement1 Lead Agency Approval FIR COMMENTS/CONDITIONS: Wt (( !S�f'-1 4QO L3 . 2 YY ltk� Zo23 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY / DATE''IE,,��RMIT# WEp1� INVOICE# Permit qoD 31�$162x 1. �f—g C 6 91W oolopT cc 12 .3 ---t z3 ? 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 294H 7-01-2023 Site Mitigation Well Pennit Application