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��auiry c <br /> SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows here. <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 Rough aril Ready Island City/State/Zip Stoddon,CA95203 Phone (209)946-0246 <br /> Cross Street wFy#estreet APN 16203007 <br /> Property Owner' Port of Stockton Phone (209)946-0246 <br /> Address 22o1Washiigton Slreet CllylStatelZlp Steckten.CA95203 <br /> C-57 Contractor Penecom aniline License# 906699 Phone (sao)6s1-36o0 <br /> Address 220NEasl Sl City/StatelZip Wbodland.CA95776 <br /> Consultant/Sub-Contractor Geosyntec Consultants Inc License# Phone 916-637-8346 <br /> Address 3043 Gold Canal Drive,Suite#100 City/Stato/Zip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 1 0 HOLLOWSTEM BORING DEPTH 20ftbgs ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) D HAMMERIDRIVEN DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TSch 40 PVC TYPE OF CASING: ❑STEEL 0PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bodng Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(A],some.0zonel 0 HANDAUGER GROUTSEALDEPTR TREMIETYPETO BE USED: 0AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Reefall Depth is 30 FI) <br /> WEWSOILBORINGIDS W-345 GROUTSPECIFICATIONS Neatcement grout -3 al water to one 47166a of Portland cement <br /> C,rIA B b F3 P —« <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel <br /> WELL IDS ❑PRESSUREGROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED �/❑AUGERS [I HOSE [I PIPE ^� ❑MUSHROOM CAP ❑3 feet below surface or r� feel below surrfacceeiiff>3 feet <br /> COMMENTS: In t�IpC�fof t� I.L"'�- J �� PAC rt0p— acf <br /> w 'l� <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 /> Signed 9::_—�j Title/Company Scientist,Geosyntec Consultants <br /> Print Name Jennifer Martin Dale 8/26/2024 <br /> EPARTMENT USE ONLY ^ / <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Date . —Z <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FAName �p FA Address Q FA# S PR# d <br /> FA PE Q1WP Reviewed By Work Plan Date 3 ZD <br /> 0C-57 57 Aulbodmdon la Otherlo Sign Permit ❑We sGoap ❑Workers Comp Waiver ❑Enrao ent Pemnt ocessA nI cad Agency Approval MFR <br /> COMMENTS/ ON ITIONS?,'42 feo S <br /> Wit %Ltsf 6-e des tira)o - u ,r s� VareV r er-Y#14' "Aiw no l ;T� se,rv�cP <br /> WP TYPE I PE I SC FEE INFO JAMT REMITTED CHECK# I RECV'D BY Aw <br /> WELL PERMIT# INVOICE# <br /> Permit 2Ro 3 i $172 x C Z <br /> 1868 E. Hazelton Avenue I Stockton, California 955905 T 209 468-3420 1 F 209 464-0138 sjcehd.co <br /> EHD 29-0708-01-2024 cc W- (3?L 14 6 3-70 Site Mitigation Well Permit Application <br />