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a/Z''°t_,r•-�a( - °° SAN JOAQUIN Environmental Health Department —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 with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address Adjacent to 1574 Laurelbrook Drive on City of Tracy sidewalk City/Statel Zip Tracy, CA 95377 Phone N/A Cross Street Dorset Lane APN N/A Property Owner* City of Tracy Phone 209-831-6000 Address 333 Civic Center Plaza 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 Consultant/Sub-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: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) - ❑ HAMMER/DRIVEN DW OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dix. Casing Depth: ❑ INJECTION fAr San,.ones) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USER ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELUSOIL BORING IDs GROUT SPECIFICATIONS - DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED One (1) Temporary Monitoring Well ®OVER-BORE DIAMETER of 10 inches to depth of 14 feel WELL Ms TW-3 ❑ PRESSURE GROUT To depth of feetbelowsudace GROUT SPECIFICATIONS Portland Neat Cement ❑EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED El AUGERS [I HOSE HIOSE El PIPE '�fI _/^{®MUSHROOM CAP ❑3 feel below surface or feel below surface if>3 feet COMMENTS: r_I rl l l I / I hereby'Ccertify yYthat I am authorized to complete this application and that the work will be done in accordance with r�San��Joaquin County Ordinance Codes and Standards, and all other applicable California laws. ,6 Signed A449141A. Title/Company Project Task Manager 1 /Arcadis US. Inc. Print Name Evan Mattern Date 8/31/2023 EP RTMENT USE ONLY Application Accepted By: 11 Date Issuedd:," Grout Inspection By/Dates 1 P 2, C � T rvy7� C)I Destruction Inspection By/Dates: "1 t C7 . I O v Facilit /Site Information r FA Name15 S FAAddress �? FA# PR# FA PE V I WP Reviewed By Work Plan Dale 3 Z ❑C-57 - 7,AulhorfatlonforothertoSignPermit ❑WAeesComp ❑Worker's Comp Waiver Ercroas_h ! Access Agreement Agency Approval �kY) COMMENTS/CONDITIONS: �[A Tw ff s f�Le t�esP�ns ;b; 7 kj 6( fikk ��p11'cr to ob�atn al! mr� u�re 4-111 0 abe -be Inn, v)6* WP TY E PE I SC I FEE INFO JAMT REMITTED CHECK# I RECV'D BY DATE WELL PERMIT# F INVOICE# Permit 2 ZI 3151s Z iI f 3 o cg�5 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 09 464-0138 www.sjce` corn EHD29-0104-20-23 Cc- / / �� /�3'119 Site Mitigation Won Pernur Application