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oUll✓-,,, <br />oh <br />` �0�' <br />SAN JOAQUIN <br />COUNTY <br />Grentncss grows here. <br />Environmental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 953=7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards, <br />Job Address 2532 Dorset Lane <br />Cross Street Laurelbrook Drive <br />Property Owner* Jian Ming Peng and Tuzhen Li <br />Address 2532 Dorset Lane <br />C-57 Contractor Penecore Drilling <br />City/State/Zip Tracy, CA, 95377 <br />APN 238-300-050 <br />City/State/Zip Tracy, CA, 95377 <br />License# 906899 <br />Phone N/A <br />Phone N/A <br />Phone 530.661.3600 <br />Address 220 N. East Street City/StatelZip Woodland,CA, 95776 <br />Consultant/Sub-Contractor Arcadis US. Inc. License# N/A Phone <br />Address 735 Tank Farm Road Suite 150 <br />City/State/Zip <br />San Luis Obispo, CA, 93401 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />805.459.2391 <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10.0 ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE In ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />M SOILVAPORPROBE ��❑ MUD ROTARY CASING THICKNESS — TYPE OF CASING: El STEEL El PVC R7 OTHER Teflon Tubing <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, Ozone l 91 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 0 PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs R-16 Dual Nested Gnil Vapor PrnhaGROUT SPECIFICATIONS Neat Cement Grout <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED <br />WELL in <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE <br />ENTS: <br />Signed <br />DESTRUCTION <br />certify that I am authorized to complete <br />this <br />application <br />and <br />that the work will be done in accordance <br />n <br />i,,�an Joaquin <br />County Ordinance Codes <br />METHOD: <br />Standards, <br />and <br />all other applicable California laws. <br />Work Plan Date <br />(CHECK <br />EIC -57 G57 Authorization for Other to Sign Permit <br />❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval )I MFR <br />COMMENTS/CONDITIONS: Dual nested vapor probe must be completely removed (i.e. overdrill) <br />separate permit. Obtain GPS coordination during inspection: <br />Submit reports/sampling results to EHD per SJC Well Standards 13.7.2 <br />ALL <br />THAT <br />WP TYPE <br />APPLY) <br />SC <br />I FEE _INFO <br />AMT REMITTED1 <br />CHECK# <br />I RECV'D BY <br />I DATE <br />I <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />12901 <br />1313 <br />$152x 1 <br />1 608 <br />1CC <br />W <br />1/25/2022 <br />❑ <br />OVER -BORE <br />DIAMETER of <br />inches to depth of feet <br />❑ <br />PRESSURE GROUT <br />To depth of <br />feet below surface <br />❑ <br />EXPLOSIVES <br />From <br />to feet below surface <br />❑ <br />MUSHROOM CAP <br />❑ 3 feet below <br />surface or feet below surface if >3 feet <br />I hereby <br />certify that I am authorized to complete <br />this <br />application <br />and <br />that the work will be done in accordance <br />n <br />i,,�an Joaquin <br />County Ordinance Codes <br />and <br />Standards, <br />and <br />all other applicable California laws. <br />Title/Company Project Manager, Arcadis US. Inc. <br />Print Name Christine Perez Date 01/10/2022 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />JEFFREY WONG <br />DEPARTMENT USE ONLY <br />Date Issued: 1 /25/2022 <br />FA Name <br />confirmation number: 137884173 SR0084768 <br />1868 E. Hazelton Avenue � Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />EH <br />CHEVRON SURLAND <br />FA Address <br />2532 DORSET <br />FA# <br />FA0007884 <br />PR# <br />PR0508012 <br />FA PE <br />2960 <br />WP Reviewed By <br />J�/ <br />Work Plan Date <br />8/30/2021 <br />EIC -57 G57 Authorization for Other to Sign Permit <br />❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval )I MFR <br />COMMENTS/CONDITIONS: Dual nested vapor probe must be completely removed (i.e. overdrill) <br />separate permit. Obtain GPS coordination during inspection: <br />Submit reports/sampling results to EHD per SJC Well Standards 13.7.2 <br />when no longer needed under <br />WP TYPE <br />PE <br />SC <br />I FEE _INFO <br />AMT REMITTED1 <br />CHECK# <br />I RECV'D BY <br />I DATE <br />I <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />12901 <br />1313 <br />$152x 1 <br />1 608 <br />1CC <br />W <br />1/25/2022 <br />1WP0042939 <br />29-01 06-28-21 Site Mitigation Well Permit Application <br />