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oultv SANsJ QAQU I N Environmental Health Department COUNTY Greatness 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 Address 9838B Old Placerville Road City/State/zipSacramento, CA, 95827 C-57 Contractor Gregg Drilling License# 1044456 Phone 925-313-5800 Address 2100 Goodyear Road City/State/zip Benicia, CA, 94510 ConsultantlSub-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 ❑ MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 24 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 6 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0.75 in TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 0 No Boring Dia: 6 In Casing Dia: 2 In Casing Depth: 23 ft ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER:Sonic GROUT SEAL PUMPED? ❑Yes ❑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 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /-'7� Title/Company Project Manager/AECOM Print Name Casey Sanders Date 08/5/25 DEPARTMENT USE ONLY Application Accepted By: Date Issued: (.Z Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information �1 FAName eut� vC(,G� L�w� FA Address 1 2, 5�—a0 1, FA# (�V t(,S t PR# Z4L FA PE "L J WP Reviewed By �� j Work Plan Date ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMM IENTS/CONDITIONS: I�l V�� --S s 04 r,C ,A, , nvV0` SL �' ( w S �..ai l.v� Su-c- I'� La.U �� S c�N� ur.�v cwt 4,rt w�G�pt O WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# !_ INVOICE# Permit 2 ��1 AL3 $179x (A X112 Z pot J��O� U! 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0107-01-2025 Zero 0-654 -654l - Site Mitigation Well Permit Application ',o{o Ba-G tq:>