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.Oyai.moi,` SAN J O A Q U I N Environmental Health Department COUNTY Gr,-,i;tness grows her. 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 23500 Kasson Road City/State/Zip Tracy, CA, 95304 Phone 916-255-3359 Cross Street 1-5 APN 23912001 Property Owner* State of California Phone 916-255-3359 Address9838B Old Placerville Road City/State/ZipSacramento, CA, 95827 C-57 contractor Geocentric Drilling License# 1073146 Phone 925-313-5800 Address 1980 S. River Rd, Suite E City/State/Zip West Sacramento, CA 95691 Consultant/Sub-Contractor AECOM License# N/A Phone 916-223-8641 Address 2020 L Street Suite 300 city/State/Zip Sacramento, CA, 95811 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS B MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 24 feet. 13 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE 6 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0 75 in TYPE OF CASING: ❑STEEL S PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: 6 In Casing Dia: 2 In Casing Depth: ❑ INJECTION(Air Soaree.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ED PIPE ❑ OTHER ❑ OTHER:SOniC GROUT SEAL PUMPED? ❑Yes m No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs MW-27,,MW-28D GROUT SPECIFICATIONS Neat Cement With 5%bentonite Slurry —2 feet BGS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �y/�r'San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /// 60 \ Title/Company President/Geocentric Drilling Print Name Michael Cramer Date 11/18{2025 DEPARTMENT USE ONLY Application Accepted By: /1ADate Issued: Grout Inspection By/Dates: 14 Destruction Inspection By/Dates: Facili /Site Information FAName 'Gu{ !p��t{/` FA Address 5—L9 L) - 550, FA# PR# FA PE ZGl WP Reviewed By �IZ 4,�V&/> Work Plan Date U --,3 ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: C2� pCvtaW,S q, / LLLS / 1f1 6 c.LwrS � { ' U 5a14, z41.L , r,P261. �J Gw L r CG�V�Vtc vt j`S G�i —GGN•u�� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RE/CV'D BY DATE f'\oWELL PE1RMMIT# INV ICE# Permit ZOO $179x 3� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4Q8-3420 I F 209 464-0138 1 www.sjcehd.com EHD 29-0107-01-2025 .)„I I .� �I).\ Site Mitigation Well Permit Application