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/,repo i cam, ( SAN JOAQUIN Environmental Health Department —COUNTY x 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 UPRR ROW, Near 2532 Dorset Lane CitylStatelZtp Tracy, CA 95377 Phone N/A Cross Street Corral Hollow Rd APN 238-010-04 Property Owner* Union Pacific Railroad Phone 402-544-2623 Address 1400 Douglas Street STOP 1690 clty/StatelZip Omaha, NE 68179-1690 C-57 Contractor TSA/Penecore Drilling License# 906899 Phone 530-661-3600 i Address 220 N. East Street City/State/Zip Woodland, CA 95377 Consultant/Sub-Contractor Arcadis US. Inc. License# N/A Phone 925-968-5012 Address 830 NE Holladay Suite#109 citylstatetzip Portland, OR 97232 CONSTRUCTION WORK TO BE PERFORMED: *Nate: Offsfte BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporAVater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBOWNG ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Diet: Casing Dia: Casing Depth: ❑ INJECTION fosexae.ozonel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 FQ WELI/SOIL BORING IDs 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 feel WELL Ds B-8 & B-9 ❑PRESSURE GROUT To depth of feetbelowsurfam GROUT SPECIFICATIONS Portland Neat Cement [I EXPLOSIVES From 0 to 1.9 feetbelaysudace TREMIE TYPE TO BE USED [I AUGERS El HOSE E)PIPEE ®MUSHROOM CAP�j ❑3 feel below surface or feet below surface if>3 feet COMMENTS: ID- l/ O a ,. Q ,y 0. -1o.M1 �e.1AJ �/�YVlTID7l Q� .rfQa�fv.� -O �- I hereby certify that II`amr authorized to complete this application and that the work will be donne in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed tMW Awu'u. Title/Company Project Task Manager 1 /Arcadis US. Inc. Print Name Evan Mattern Date 8/31/2023 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: 'V - f/ V Destruction Inspection By/Dates: 2 GI. �.OIJ Faclllt /Site Information A ✓ Z) to C>JbV FA Name J FA Address �"� FA# 4 PR# 0y ra FA PE q Q WP Reviewed By Work Plan Date q/j Z/202.3 6 / 0C-57 57 Automation for Olherto Sgn Permit ❑Workers Comp ❑Workers Gomp Walver ❑Encroachment Permit ❑Access Agreement Le ad Agency Approval FR COMMENTS/ ONDITIONS: ItCU- I C Z ;- zy-� WP TYPE I PE I SC I FEE INFO JAMT RENUTTED1 CHH+E�CK# RECV'D Y DATE ELL PERMIIjT#/' INVOICE# Permit D2 3 7 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209A68-1342011 F 209 464-0138 �vww.�ehd.A EHD 29-M04-20-23 ce (- 6? r.- ritt 2 Sit.Mifigation Welh Pernt Application (tfOS-vit VZ- -V Z431 7 1