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SAN J �AQUlN Department Environmental Health COUNTY cqr 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 with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 780 E 6th Street City/State/Zip 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 City/State/Zip Rio Linda,CA 95673 Consultant/Sub-Contractor Antea Group License# Phone 737-279-9848 Address 11010 White Rock Rd City/State/Zip Rancho Cordova,CA 95670 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 5 at 10',1 at 25' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.375" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA NA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER NA ❑x SOIL BORING 6 ❑x PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ©No Boring Dia: NA Casing Dia: NA Casing Depth: NA ❑ INJECTION(Air Soarge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes x❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs B-1,B-2,B-3,B-4,B-5,B-6 GROUT SPECIFICATIONS 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 [:1HOSE [:1PIPE ❑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 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed 2ff�o � Title/Company President/Confluence Technical Services,Inc. Print Name Ralph McGa ey Date 02/21/2024 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $162 x 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 7-01-2023 Site Mitigation Well Permit Application