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SA N J 0 A 0 U I N Environmental Health Department <br /> C O U NTY----- <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 9-1116.3, and the San Joaquin County Well Standards, <br /> Job Address Rough and Ready Island City/Statolzip Stockton,CA 95203 Phone <br /> Cross Street W Fyffe Street APN 16203007 <br /> Property Owner* Port of Stockton Phone (209)046-0246 <br /> Address 2201 Washington Street Citylstate/Zlp Stockton,CA 96203 <br /> C-67 Contractor PoneCore Drilling License# 906899 Phone (530)661-3600 <br /> Address 220N East St City/St,t,/Zfp Woodland,CA 95776 <br /> Consultant/Sub-Contractor Ge. osyntecConsultatits Inc License# Phone (916)637-8321 <br /> Address 3043 Gold Canal Drive,Suite#100 citylstate/zip Rancho Cordova,CA 96670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: OffsIte Borings/Wolls Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING '[3 HOLLOW STEM BORING DEPTH 0 BOLTED TRAFFIC BOX U STOVEPIPE <br /> [I EXTRACTION(VaporMaler) El HAMMER/DRIVEN DIA,OF BOREHOLE 0 MULTIPLE CASINGS I-)MULTI-LEVEL WELL CASING DIA <br /> D SOILVAPORPRO13E [I MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL 0 PVC 1-1 OTHER <br /> El SOIL BORING Ll PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes [I No Boring Dk Casing Dia:_Casing Depth: <br /> El INJECTION jAir Sparge.Ozone HANDAUGER GROUT SEAL DEPTH TREMIF TYPE TO BE USED: El AUGERS L1 HOSE El PIPE <br /> El OTHER ❑ OTHER:— GROUT SEAL PUMPED? 0 Yes D No (Note:Maximum Freefall Depth Is 30 FI) <br /> WELL!SOIL BORING 10s GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 11 -} les AW10( 0 OVER-BORE DIAMETER of—inches to depth of feet <br /> WELL IDs See attached table ovt J13;jrck- <br /> PRESSURE GROUT To depth of—feet below surface <br /> GROUT SPECIFICATIONS Neat cement grout-3gal water to 1 471b bag of portland cerhenEl EXPLOSIVES From—to—feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS El HOSE El PIPE El MUSHROOM CAP Ll 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS' See list of attached wells and well information.All IDW will be hauled off by a hazardous waste company. <br /> I hereby certify that I am authorized to oomplote.thIs application and that.the.work will be.done In accordancewith <br /> ....... San Joaquin County Ordinance Codes and Standards,and oil other applicable California laws. <br /> Signed Title/Company Sclentst,Geosyntec <br /> Print Name Catherine Mear CAXO—�;4� Date 9/8/2022 <br /> P RTMENT USE ONLY <br /> j Uk'q- - /,5--Application Accepted By: tA ;�j C 4 Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates:_0�jw <br /> Facilitv/Site Information <br /> A\ <br /> FA Name FA Address y J FA# PRU <br /> FA PE 4y WP Reviewed By Work Plan Date q / I /F 2 <br /> DC-57 C-57 Aultiorization for Other to Sign Perm!( ElftkeesConnp ❑Workers c6mp Waiver [DEncroachment Pemilt [I Access Agreement KLeadApncyApproVdt�OFR <br /> COMMENTS/CONDITION <br /> y- T-U!—7A <br /> r lay'v <br /> 0 <br /> v) r <br /> N 'P11 M r)4- 9 M 124 innerC'� <br /> WP WOE PE FEE INFO AMT arMiTTIED1 bHEC'K#I RECWD BY DATE WELL PERMIT I INV­0ICE# <br /> Permit $156 <br /> '- ' �A <br /> '-rd q1jk2jjk,�'? ()0t4 3 z"0 <br /> 1868 E. Hazelton Avenue I Stockton, California T 2'09qW-h2"0 qI'-'F 209 464-00018�=jcel-id,com <br /> EHD 29-0104-04-07 (-+Ai 5 % C-C +(j"� �'L �� Site Mitigation Well Permit Application <br /> gcv�4 %I f 3 1 z 0 ZZ 69 'X%-J <br />