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SAN J �AQUlN Department Environmental Health COUNTY cqr 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 309 W.Yosemite Ave&105 Sycamore Ave City/State/Zip Manteca,CA,95336 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 City/State/Zip Manteca/CA/95337 C-57 Contractor TEG-Northern California License# 706568 Phone 916-853-8010 Address 11350 Monier Park PI City/State/Zip Rancho Cordova,CA,95742 Consultant/Sub-Contractor 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 Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH —15-20 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA © SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER © SOIL BORING 3 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Surge,Ozone) ❑ 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-1 through ASG-3 GROUT SPECIFICATIONS DP-1 through DP-3 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #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 [:1HOSE ❑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 soil 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 in County Ordinance Codes and Standards,and all other applicable California laws. �Signed Z Title/Company PG No 9945,Condor Earth Print Name Luke Castle Date 4/12/2024 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $162 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 7-01-2023 Site Mitigation Well Permit Application