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CLOWN SAN �tJOAQUIN Environmental Health Department COUNTY— i,,;,' , 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. i' 's S i � add ress 45 ©o l acl�TJTti2 � c 0s o �• �c ) Job Address -BN Atrsr!ktmrirht rnheds4Fac-11ily-AW od- City/State/Zip Stockton,CA 95215 Phone 209-460-6476 Cross Street J9ck Sene-Rdad A P-C_H APN 18117007 Property Owner* BNSF Railway Company Phone 913-551-4591 Address 11925 W.Thompson Ranch Rd City/State/Zip El Mirage AZ 86335 C-57 Contractor Cascade Drilling License# 1058336 Phone 510-478-0858 Address 345g Collins Ave City/State/Zip Richmond CA 94806 Consultant/Sub-Contractor TRC (Consultant) License# 409606 Phone 925-494-4385 Address 1850 Gateway Boulevard Suite 1000 CltylStatelZip Concord, CA 94520 CONSTRUCTION WORK TO BE PERFORMED: *Note: Ogsite BoringsM/ells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING UN MBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BOmNG DEPTH 1.5It-15it ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporM'ater) ❑ HAMMERDRIVEN DIA.OF BOREHOLE 3 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL El PVC ❑ OTHER M SOILBORING 6 OPT M PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dix Cuing Depth: ❑ INJECTION GHsexoe,Om.) 7 M HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELUSOILBORINGIDs 8-tthrou hB-13 GROW SPECIFICATIONS Bodrgs vAl be grouted upon completion. VY ' DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) It WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑PRESSUREGROUT To depth of feet beiowsudace 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 surface if>3 feet COMMENTS: Complete 13 soil borings to depths of 1.5 feel(6 locations), 6 feet(1 location), 10 feet(3 locations), 15 feet(2 locations), and 25 feet(1 location). Soil samples will be collected and borings will be grouted upon completion. Please EXPEDITE permit processing --will pay the 1.5x fee rate. 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_a(,p— 2�— Title/Company Project GoologlstITRC Print Name Laura Tait Date 3/1512023 DEPARTMENT USE ONLY Application Accepted By: Dale Issued: 1 3/ .Cn I Grout Inspection By/Dates: Destruction Inspection By/Dates: 1AI Facilit /Site Information FA Name f) l7f - FAAddress I 1 Iq25 ' •o'M Sm'� FAR Uo275g9 Pal () 54$ '331 FAPE WP Reviewed By 5 Vv I Work Plan Date *Z_0Z_? ❑C-57 G57A9IhodzagonlmOlherto Sign Pemit ❑Workers Gomp ❑WAers ComppWaiver ❑Enmoachment Permit ❑Access Agreement ❑Lead AgencyApproyal N. FR COMMENTS/C NDITIONS: 5..6w1;-(- 112TOrk IreS t .`S fIt> &HD per -5,TC' ?_R S-(Y4yt d ni,4 S I�,� WP TYPE PE SC I FEE INFO JAMT REMiTTED1 CHECK# I RECV-D BY I DATE WELL PERMIT# INVOICE# Permit �qo 313$ 46 $ Q �vJ 13 NOW 1 W PODT43�� r5s� `Z5++0 SaLDoB � Z 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sjceh com EHD 29U104-04-07 Site Mitigation Well Pemdt Applloadon