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SAN.�JOAQUIN Environmental Health Department rs:+ Greatness grows hero. 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 2502 Dorset Lane city/Statelzip Tracy, CA 95377 Phone N/A Cross Street Laurelbrook Lane APN 238-300-08 Property Owner' Marciano Heredia Phone N/A Address 2502 Dorset Lane City/State/Zip Tracy, CA 95377 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/Statelzip Portland, OR 97232 CONSTRUCTION WORK TO BE PERFORMED: *Note: ORsite BoringsAVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapaAVater) 0 HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Romig Dia: Caring Dia: Casing Depth: ❑ INJECTION(AFsoarae.ozawl ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: [I AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 FQ WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED One (1) soil vapor probe E3 OVER-BORE DIAMETER of 3_5 inches todepth of 8.3 feet WELL IDS 13-14 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland Neat Cement ❑EXPLOSIVES From_0 to 8.3 feetbelowsudace TREMIE TYPE TO BE USED [I AUGERS [I HOSE n PIPE ®MUSHROOM CAP ❑3 Left belows rface or feet below suda73 feet COMMENTS: // a r ��,� —PZ{ 6s6 C1 2 r u Zvb u IA o f n 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 AQ vu. Title/Company Project Task Manager 1 /Arcadis US. Inc. Print Name Evan Mattern Dale 8/31/2023 EPAFerMENT USE ONLY 2 /ZO Z�Application Accepted By: t Dale Issued: 14 Grout Inspection By/Dates: Destruction Inspection By/Dates: G Facilit /Site Informs on AL '^ FA Name FA Address ZJ p � FA# Q0v1-� PR# 059 0 0 FA PE 1 WP Reviewed By Work Plan Date 0 0-3 ❑C-57 f&57AuftmaUomkrOthertoftnPemhi1 ❑Workers Comp ❑Workees Comp Waiver ❑Encroacbment Permit ❑Access Agreement ead Agency Approval MER COMMENTS/C N ITIONS: WP TYPE PE I SC I FEE INFO AMT RFMiTTEDj CHECK# I RECV'D BY AT WELL PERMIT#�y INVOICE# --1 Permit - v2 s f uA I g I ( Wr0,-0�/�7/--X1 S 1868 E. Hazelton Avenue I Stockton, California 95 ¢� �09 468-3420 1 F 209 464-0138 1 Sd�T y h J.com EHD 29M 04-20-23 cc b qrL* + Ibfr2hpl Site Mitigation Well Perouil Applicafion ttU( - A 1 _ ,ou T ✓O pl