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S A N J OA Q U I N Environmental Health Department °; I „_. COUNTY Greatness grows here, 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 Rough and Ready Island City/State/Zip Stockton, CA 95203 Phone Cross Street W Fyffe Street APN 16203007 Property Owner* Port of Stockton Phone (209)946-0246 Address 2201 Washington Street City/State/Zip Stockton, CA 95203 C-57Contractor PeneCore Drilling License# 906e99 Phone (530)661-3600 Address 220 N East St City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor Geosyntec consultants Inc License# Phone 916-637-8048 Address 3043 Gold Canal Drive, Suite#100 City/State/Zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 1 ® HOLLOW STEM BORING DEPTH 23' ® BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 8" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 2"Sch 40 PVC TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dial: Casing Dia: Casing Depth: ❑ INJECTION(Air Saarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ® Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs PMW-01 GROUT SPECIFICATIONS neat cement mix, 3 gallons of water per 471b bag of cement 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: See attached well information. All IDW will be hauled off by a hazardous waste certified company 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 Title/Company Staff Scientist at Geosyntec Consultants Print Name Jennifer Martin Date October 26, 2022 DEPARTMENT USE ONLY / Application Accepted By: Date Issued: Grout Inspection By/Dates: ] V V LZ ,G L0 0(✓0 WE�1 Destruction Inspection By/Dates: Facilit /Site Information FA Name (� FA Address d a FA# S PR# To75T4 FA PE WP Reviewed By Work Plan Date ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS: S — 1 C Yl�wwi YMi� w rCi .a� � WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE rWELL PERMIT# p INVOICE# Permit 2�(�( j $1 6 52 x . 5 �� -1) w 0 h;1 Z 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34�0 1 F 209 464-0138 I www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application