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SAN IUAgUIN <br />GreoUless gfc>>vs (�ei <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />4. Hours Advance Notice RegLlilred For All Inspections <br />CALL (209) 9534697 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 />ip <br />Cross Street Tracy Hills Dr <br />Property Owner* ICGC, LLC <br />Address 24 West 10th St <br />C-57 Contractor Cascade Drilling <br />Address <br />3459 Collins Ave <br />ConsultantlSub-Contractor Haley &Aldrich, Inc. <br />Address 2033 N Main St, Suite 309 <br />City/statelZ <br />CTracy/CA/95377 Phone <br />APN 251-060-100-000 <br />City/statelZip Tracy/CA/95376 <br />License# 1058336 <br />City/StatelZip <br />Lic <br />Richmond/CA/94806 <br />ense# <br />State/Zip Walnut Creek/CA/94596 <br />Phone <br />510-478-0858 <br />Phone 714-371-1805 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ hAONITORING ❑ HOLLOW STEM BORING DEPTH 10 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (VaporMater) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 3.25 in ElMULTIPLE CASINGS ElMULTI-LEVEL WELL CASING DIA <br />IN SOIL VAPOR PROBE 2 [:1MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />SOIL BORING 2 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes (4 No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air sparge, ozone) (X] HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes (4 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELUSOILBORING IDs _ B-5 B.6 (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 2 ❑OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs B-5 13-6 ❑ PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS Bentonite ❑ EXPLOSIVES From _ to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br />COMMENTS: <br />Signed <br />Print Name <br />I hereby certify that I 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 />Title/Company Senior Project Manager/Haley & Aldrich, Inc. <br />Jason Grant Date 12/8/21 <br />V <br />DEPARTMENT <br />USE ONLY <br />Application Accepted By: / Date Issued: C�/ <br />t ; <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facilit (Site Information _ <br />FA Name FA Address S�gv FA# �Y PR# (� <br />FA PE P WP Reviewed By vt/ Work Plan Date 8 2 <br />ElC-57 L&57 Authorization for Other to Sign Permit ❑ Worker's Comp ElWorker's Comp Waiver ElEncroachment Permit ElAccess Agreement ElLead Agency Approval MFR <br />COMM ENTS/C NDITIONS: re <br />1868 E. Hazelton Avenue � Stockton, California 95205 <br />EHD 29-01 06-28-21 <br />T 209 468-3420 � <br />s <br />F 209 464-0138 � www.sjgov.org <br />Site Mitigation Well Permit Application <br />