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4 <br /> r <br /> SAN -JOAQUIN Environmental Health Department <br /> —COUNTY <br /> realness grows here. <br /> ^�� SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r ours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <br />' S19, Is hereby made to San Joaquin County for a permit to construct and/or Install the Work described. <br /> n <br /> xv This appii Is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> jhA re s 1535 East Pescadero Avenue city/statelzip Tracy, CA 95304 Phone N/A <br /> Cross Street-, McArthur Drive APN 213-060-200-000 <br /> Property Owner' YRCInc. Phone N/A <br /> Address 10990 Roe Avenue City/Statelzip Overland Park, KS 66211 <br /> C-57 contractor Environmental Control Associates License# 695970 Phone (831) 662-8178 <br /> Address 3011 Twin Palms Drive chy/Statelzip Aptos, CA 95003 <br /> ConsultanUsub-Contractor AEI Consultants License# Phone (408) 442-2605 <br /> Address 2500 Camino Diablo City/staterzip Walnut Creek, CA 94597 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Welis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 24 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERNRIVEN DW.OF BOREHOLE 2.25 inches ❑MULTIPLECASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS N/A TYPE OF CASING: El STEEL [I PVC ❑ OTHER <br /> MI SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes IM No Boring Ds: Casing Dia: Casing Depth: <br /> ❑ INJECTION GFsesm,,o.) ❑ HANDALIGER GROAT SEAL DEPTH : ❑AUGERS 14QSE El PIPE <br /> ❑ OTHER ® OTHER:Direct Push GROUTSFAL PUMPED? ❑Y ®No (Note:Maximum Freefall DeMh Is 30 Fill 9P - <br /> WELD SOIL BORING IDS SB-I throllgh SB-7 GROUT SPECIFICATIONS C L r <br /> ME <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTIO METHOD: tCHECK ALL THAT AP PLY) 5 ttiLl• -p f— 1 <br /> #WELLS TO BE DESTROYED N/A ❑OVER-BORE DIAMETER of_inches to depth of feet �� <br /> WELL IDs ❑PRESSURE GROUT To depth of feetbelowsudace 1 <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO cBE1 USED ❑AUGERS [I HOSE PIPE [I MUSHROOM CAP Elfeel below surface or feel bet udace if>3 feet <br /> COMMENTS: GItY ' AG I Wer A4l SAN 101Zo-L4 '', lb rnsi `i- -I- <br /> 9ro .� ko be usC6Z . eFiD w l -F�I� ire fir' <br /> I hereby certify that I am authorized to complete this applicaticn and that the work will be done in accordance with <br /> 4-al San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed � ) Title/Company Project Geologist/AEI Consultatts <br /> Print Name Natasha Budimirovic Date 1/8/2023 <br /> PARTMENT USE ONLY A ^ <br /> Application Accepted By: Dale Issued: CX� C� <br /> Grout Inspection By/Dal : r <br /> Destruction Inspection By/Dales: a ' <br /> Facilit /Site Information 4� eS a P614 <br /> FA Name �3 qy(- �C � M FA Address �' FA# �V r, � D I t I PR# 3 <br /> FA PE WP Reviewed By Work Plan Date A. I D 2,Lj <br /> `Q/ryI ❑C-57 57AulhorizztionforOtherlo Sig�ni'munit ❑Workers Comp ❑Worker's Comp Waiver ❑Enao ment Permit ❑Aoxss Agreement ❑Lead Agency Approval FR <br /> Z EN 4 , TION3`• /tV ICS 1. Vj I v <br /> t D✓21�' <br /> WP TYPE I PE S FEE IINFO REMITTED CHECK# RECV'D BY T WELL PERMIT# INVOICE# <br /> Permit $i _2 L <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 L F 209 464-0138 WwWr sice d.conn <br /> EH029-U104.20-23 M . I- If� G C �11Z Site Mitigation Well Permit Application <br />