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i <br />a�'%''�a <br />AN lOGOUIN <br />COUNTY <br />GreOtness gF01"t's I]Cf Os <br />SITE MI I JUA 11111 WELL S DVMIIMWJ rF�MIlfili V -1V <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 Hours Advance Notice Required For All Inspections <br />CALL (209) 9537697 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 I-580 EB/Corral Hollow Rd Exit Ram <br />Cross Street Tra <br />Property Owner* <br />Hills Dr <br />ICGC. LLC <br />CitylStatelZip Tracy/CA/95377 Phone <br />APN 251-060-120-000 <br />Phone <br />Address 24 West 10th St CitylStatelZip Tracy/CA/95376 <br />C-57 Contractor Cascade Drilling License# 1058336 Phone .51 0478-0858 <br />Address <br />3459 Collins Ave <br />ConsultantlSub-Gontractor Haley &Aldrich, Inc. <br />Address 2033 N Main St, Suite 309 <br />City/state/zip Richmond/CA/94806 <br />License# <br />CitylStatelZip Walnut Creek/CA/94596 <br />Phone 714-371-1805 <br />CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />ElEX)RACTION (VaporMater) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 3.25 in ElMULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />(� SOIL VAPOR PROBE 4 [1MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ElSTEEL El PVC ElOTHER <br />SOIL BORING 4 PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: Casing Depth: <br />ElINJECTION (Air Sparge, Ozone) (SI HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS El HOSE [I PIPE <br />ElOTHER ❑ OTHER: GROUT SEAL PUMPED? El Yes [4 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs B-1 to B-4 (see Figure 2 in GROUT SPECIFICATIONS <br />Work Plan) <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED 4 ❑OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs B-1 to B-4 F]PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS_ Bentonite ElEXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED E]AUGERS ❑ HOSE E]PIPE E]MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br />COMMENTS: <br />I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print Name Jason Grant <br />Application Accepted By: t <br />Grout Inspection By/Date <br />Destruction Inspection By/Dates: <br />Title/Company Senior Project Manager/Haley &Aldrich, Inc. <br />Date 12/8/21 <br />ENT USE ONLY <br />r <br />ra�un tuna nr�inauv <br />FA Name <br />FA PE <br />ff <br />WP Reviewed By <br />�'' <br />Work Plan <br />Date <br />g 2 <br />❑ C-57 Authorization <br />for Other to <br />Sign Permit <br />❑ Worker's Comp ❑ Worker's Camp Waiver ❑ <br />Encroachment Permit <br />❑ Access Agreement <br />❑ Lead Agency App <br />oval FR, <br />COMMENTS/C NDITIONS: <br />� � <br />(1,,(1U, <br />INVOIGE# <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DNE - <br />WELL PERMIT# - <br />Permit <br />zj <br />$152 x <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wvvw.sjgov.org/ehd <br />FHD 29-01 06-28-21 Site Mitigation Well Permit Application <br />2 <br />