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SAN JOANIN Environmental Health Department --- COUNT Y---- ,, Gn'ulness qro �-: hem. 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 9-1116.3, and the San Joaquin County Well Standards. Rough and Ready Island Stockton, CA 95203 Job Address CltylStatelZip 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-57 Contractor PeneCore Drilling License# 906899 Phone (530) 661-3600 Address 220 N East St City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor Geosyntec Consultants Inc License# Phone (916) 637-8321 Address 3043 Gold Canal Drive, Suite#100 City/Slate/Zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offshe BoringsfvVelis Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXrRACTION(VaporM'ater) ❑ HAMMEWDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑ MULTI LEVEL WELL CASING DR ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(OP/CPT) CONDUCTORCASING ❑Yes El No Boring DO! Casing Dia: Casing Depth: ❑ INJECTION(Air Searee.ozone l ❑ HAND AUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: El AUGERS ❑ HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth Is 30 Fit WELU SOIL BORING Ina GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 11 ® OVER-BORE DIAMETER of_inches to depth of <90 feet WELL IDs See attached table ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat cement grout-3gal water to 1 4711b bag of portland cemen❑ 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 feel COMMENTS: See list of attached wells and well information.All IDW will be hauled off by a hazardous waste 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 Scientist, Geosyntec Print Name Catherine Mear Date 9/8/2022 /} q �T � DEPARTMENT USE ONLY Date Issued: G�� C✓Application Accepted By: fY( t,--FffJ —� Grout Inspection By/Dates: U t Destruction Inspection By/Dates: Facilit /Site Information FA Name POD FAAddress FA# (}0 Z,5 I PRO j�^ FA PE vy Wle Reviewed By Work Plan Date 2 0057 C-11 Aulhodzagon for Other to Sign Permit ❑Worketscom ❑Workers Cbmp Waiver ❑❑Encroachment Permit El Access Agreement Lead Agency Approval MFR COMMENTS/C NDITIONS: ',,, p( Lfeq i6� n8 b vow , 6�. k G _ e h1 GD ' � 621, IA WP TYYr I PEU "� {7 FEE INFO AMT ITTED bHHreECK# RECWD BY s3 DATE WELL PERMITS INVOICE# Permit Q <_7gJ �15�c 7( li Ci Q19 2 ^Jr �,°1 '� ...2 �r� _ 1868 E. Hazelton Avenue Stockton,California 95205 i T 209 WA20 F 209 464 0138` (ww.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Applicallon