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SAN JOAQUIN Environmental Health Department a COUNTY Greatness grows Kerr. 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 West Side Irrigation District, Near 2532 Dorset Lane City/Statel Zip Tracy, CA 95377 Phone N/A Cross Street Corral Hallow Rd APN 238-600-31 Property Owner' West Side Irrigation District Phone 209-835-0503 Address 1320 N. Tracy Boulevard City/State/Zip Tracy, CA 95376 C-57 Contractor TSA/Penecore Drilling License# 906899 Phone 530-661-3600 Address 220 N. East Street City/State/zip Woodland, CA 95377 ConsultanUSub-Contractor Arcadis US. Inc. License# N/A Phone 925-968-5012 Address 830 NE Holladay Suite#109 City/State/Zip Portland, OR 97232 CONSTRUCTION WORK TO BE PERFORMED: 'Note: OffsHe Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapof Water) ❑ HAMMERA)WVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELLCASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING El Yes [I No noting Diz: Casing Dn Casing Depth: ❑ INJECTION Wswrae.Ozeeel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS El HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? El Yes [I No (Note:Mrdmum Rental Depth is 30 FQ WELU SOIL BORING Ins GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED TWO (2) Soil Vapor probes ®OVER-BORE DIAMETER of 4 inches to depth of 15 feet WELL IDs B-10 & B-11 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland Neat Cement ❑EXPLOSIVES From to 1_feetbelaysudace TREMIE TYPE TO BE USED [I AUGERS El HOSE PIPE ®MUSHROOM CAP ❑3 feel below surface of feet below surface if>3 feel COMMENTS: 7 (q4m 0-Lt ! (5� � -J t L�, I— ra11 `R B (4 � C 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 &AW AQUVM. Title/Company Project Task Manager 1 /Arcadis US. Inc. Print Name Evan Mattern Date 8/31/2023 DEPARTMENT USE ONLY Application Accepted By: Dale Issued: -/ /� �ho L3 Grout Inspection By/Dates: Destruction Inspection By/Dates: z,r LJ pU J Facllit /Site Information FAName 15.1VIL45 FA Address 2 Qw]- FA# D O PR# 10 So eo FA PE WP Reviewed By Work Plan Date I TItelz—am-3x •1 1 0057 57A0Badza6on for Other to Sign Permit ❑Workers Comp ❑Wpkefs Comb Waiver ❑Enaoachmenl Permit ❑Access Agreement Lead Agency Approval MFR COMMENTS/ ONDITIONS: - WP TYPE PE I SC I FEE INFO JAMT REMITTED CHECKK# RECV'D BY (y DATE, IWEL/Ly-PERMIT# INVOICE# Permit oZ 3i3 'IGCYSVV eW� �( . 1868 E. Hazelton Avenue I Stockton, California 952 I J �9 468-3p420 1 F 209 464-0138 1 vGww�s fit .001n 5 EHD 29-0104-20-23 pj git 1 Site Mitigation Well Pendt Application 14 -ILL = itt