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7. SA N JOAQUIN Environmental Health Department COUNTY °qC/ P 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 600 N.Main St. City/State/Zip Manteca,CA 95336 Phone 209-649-3440/669-777-8616 Cross Street E. Edison St. APN 223-141-17 Property Owner* Sav-In Management,LLC; Indra and Savitri Yadav Phone 209-649-3440 / 669-777-8616 Address 3462 Rutherford Drive City/State/Zip Stockton,CA 95212 C-57 Contractor Cascade Drilling; Project Manager: Rick Alcartado License#1058336 Phone 510-772-0841 Address 3459 Collins Ave City/State/Zip Richmond,CA 94806 Consultant/Sub-Contractor AECOM; Project Manager:Wanda Farmer License#California Contractor's License:641639 Phone 843-209-1534 Address 300 Lakeside Dr,Suite 400 City/State/Zip Oakland,CA 94612 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 and 15 ft R! BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3 1/4 inches ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA 50 SOIL VAPOR PROBE 7 El MUD ROTARY CASING THICKNESS 2 inches TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia:3 1/4 inches Casing Dia: 2 inches Casing Depth: 5 and 15 ft ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ® OTHER: Direct Push GROUT SEAL PUMPED? Co Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SG-1,SG-2, SG-3,SGA SG-5.SG-6.and SG-7 GROUT SPECIFICATIONS The borehole will consist of 1 ft of sand at the base,followed by 1 ft of dry bentonite,1 ft of hydrated bentonite,an additional 1 ft of sand,a granulated bentonite plug atop of the sand,and grouting will fill the borehole until the surface is reached. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑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 surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with Casaus sarb jQ09Yi 1bPQMA1ty Ordinance Codes and Standards,and all other applicable California laws. Maureen Signed ' DN:c^=Casaus,Maureen, Title/Company AECOM Technical Services, Inc. a u re e n Casaus@aecom.com Print Name Date:2023.10,0316:07:18-07'00' Maureen Casaus Date 10/3/023 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/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 $156 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 04-20-23 Site Mitigation Well Permit Application