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SAN JOAQUIN Environmental Health Department COUNTY— - �'��rro�':` 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 1535 East Pescadero Avenue City/State/Zip Tracy, CA 95304 Phone N/A Cross Street N. McArthur Drive APN 213-060-200-000 Property Owner* YRC Inc. Phone N/A Address 10990 Roe Avenue City/State/Zip Overland Park, KS 66211 C-57 Contractor Environmental Control Associates License# 695970 Phone (831) 662-8178 Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 ConsultanttSub-Contractor AEI Consultants License# Phone (408) 442-2605 Address 2500 Camino Diablo City/State/Zip Walnut Creek, CA 94597 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 24 feet ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 inches ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ® SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS_ ❑HOSE ❑PIPE ❑ OTHER ® OTHER:Direct Push GROUT SEAL PUMPED? ❑Ye ®No (Note:Maximum Freefall Depth is 30 Ft) iC" WELL/SOIL BORING IDs SB-1 throuffh SB-7 GROUT SPECIFICATIONS A& 1 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTId METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED N/A ❑ 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 urface if>3 feet COMMENTS: Aei I tj i tt,(;L Si-v. to , ZOZ,4 ", A� 'f"�P� rs 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 Project Geologist/AEI Consultatns Print Name Natasha Budimirovic Date 1/8/2023 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dat : Destruction Inspection By/Dates: Facilit /Site Information FAName e,k 'Pe 64 FA Address C FA# a L , PR# y' FA PE �/ WP Reviewed By Work Plan Date t (G' ,(;�,� ❑C-57 [?A 57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑ Lead Agency Approval MFR COMM ENTS/CON 'ITIONS: J AUL ff � . 6 h(� � 19 P . , s �� ` -s - fly ( S A WP TYPE PE S FEE INFO 4ndT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit q:LZG /i�� ' ! 1 �G� oo 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 LF 209 464-0138K��'� .sjce44.om EHD 29-01 04-20-23 ^. I� V (� L i•�� Site Mitigation Well Permit Application ILL- ,�t 1't' �' -7