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SAN JOAQUIN Environmental Health Department COUNTY ` ,r (arentnr?ss gr-nws �ler�. 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 andlor 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 309 W.Yosemite Ave&105 Sycamore Ave City/State/Zip Manteca,CA,06336 phone Cross Street Manteca Ave APN 217-210-100&217-210-110 Property Owner" City of Manteca Phone 209.456.8562 Address 1215 W.Center Street,Suite 201 CitylStatelZip MantecalCA/95337 � C-57 Contractor TEG-Northern California License# 706568 "G 3 1'phone 916-853-8010 Address 11350 Monier Park PI CitylStatelZip Rancho Cordova,CA,95742 Cons ultant/Sub-Co ntracto r Condor Earth,Luke Castle License# PG No.9945(Luke Castle) phone 209.513.7634 Address 188 Frank West Circle,Suite I City/State/Zip Stockton,CA,95206 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite 13oringslWells Require Access Agreements or Encroachment Permits TYPE OF WELLISORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH --15-20 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.25` ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ® SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER © SOIL BORING 3 ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION Q 3oarae.ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs ASG-1through ASG-3 GROUT SPECIFICATIONS DP-1 through DP-3 say� uU � � DESTRUCTION WUKTOBE PERFORMED: DESTRUCTION METHOD:(CHECK ALL ` THAT APPLY) � If WELLS TO BE DESTROYED ❑x OVER-BORE DIAMETER of 2.25 inches to depth of -15-20 feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Type I and Type II ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [--]AUGERS ❑HOSE ❑x PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: ASG-1 through ASG-3 to be temporary multi-completion self gas wells screened at 5 and 15 feet bgs. DP-1 though DP-3 are direct push borings to obtain grab groundwater samples and soil,samples,if warranted(see work plan) Wells to be destroyed pursuant to SJCEHD Well Standards I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San_Joa Icy n County Ordinance Codes and Standards,and all other applicable Californla laws. Signed /41u/�_ C/��"/ Title/Company PG No 9945,Condor Earth Print Name Luke Castle Date 4111212024 DEPARTMENT USE ONLY / 2,L 2.02 Application Accepted By: Dale Issued: r Grout Inspection By/Dates: Destruction Inspection BylDates: Facifit !Site Information, FA Name y t.S,,.e t �41� FAAddress { 45 ( FA# $ -f PR# FA PE O WP Reviewed By Work Plan Date I It 2 20 2 ❑C-57 C-57 Authorization for Other to Sign Permit ❑Wofkees Comp El Workers Comp Waiver ❑Encroachment Permit ElAccess Agreement ❑Lead Agency Approval MFR COMMENTS/CONDITIONS: I�`e; G�/„ q&Cr r4yAwAxt fo fC-1f'm P C- WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Q� .313 $162 X g �� C C i 'o �„ �sq-,S+- ��R S cgs ( is�oag� qG� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464- 38 I www.sjcehd.com FHD 29-ei 7-01-2023 Site Miugauon"%II Permit Appifeation