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SAN JOAQUIN Environmental Health Department COU NTY 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 2532 Dorset Lane City/State/Zip Tracy, CA 95377 Phone N/A Cross Street Laurelbrook Lane APN 238-300-05 Property Owner* Jian Ming Pang and Tuzhen Li Phone N/A Address 2532 Dorset Lane CltylStatelZip 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 Consultant/Sub-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: Offsite Borings=ells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ RAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(BYsoarnaozanl 0 HANDAUGER GROUT SEAL DEPTH THEMIETYPETO BE USED: ❑AUGERS [I HOSE [I PIPE [I OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Madmum Fre/fall Depth is 30 P) WELL]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 91 OVER-BORE DIAMETER of 3.5 inches to depth of 8.3 feel WELL Ins B-13 & B-16 ❑PRESSURE GROUT To depth of feel below surface GROUT SPECIFICATIONS Portland Neat Cement ❑EXPLOSIVES From 0 to 8.3 feet below sudace TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE PqPIPE N MUSHROOM CAP �— if ❑3 feet below surface or feet below surface >3 feet GWI COMMENTS:u tt � rr & TEW T&_ c.5. ct-0j-� PcLf ^Y O P--O 1I �1 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 S," At4(tn1, Title/Company Project Task Manager 1 /Arcadia US. Inc. Print Name Evan Mattern Date 8/31/2023 1f—�p DEPARTMENT USE ONLY Application Accepted By: 1A Date Issued: Grout Inspection By/Date Destruction Inspection By/Dates: Facilit /Site Information M r FAName S�. FAAddress �e FA# DW PR# Q7j DI� FA PE WP Reviewed By Work Plan Dale 2 023 b f - ❑C-57 W 57fthenzabonfor Other to Sign Permit ❑Workers Comp ❑Wolkees Comp Waver ❑Encroachment Permit ❑AccessAgmement ad Agency Approval COMMENTSICON DITI ON S: WP TYPE PE I SC FEE INFO AMT REMITTED CHECK# RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit I D _rJ3 3lbzX I I bZ I CC )z 2 Wo0 95 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F. 209 464-0136 T4�Ww.sjcena com EHD 29-01N-20-23 CC *f / 6 O , I, Site Mitigation Well PemYt Application ZLfZ --/Lz- �1 � l/J A C1�