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IED >Bey SAN JOAQUIN COUNTY FEBENVIRONMENTAL HEALTH DEPARTMENT E13 2017 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEAM Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sucehd.com PERMIT/SERVICE SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 2480 Toste Road City1State1Zip Tracy.CA 95377 Phone (209)481-9386 Cross Street Grant Line Road APN 238-060-027 Property Owner* Rod Toste Phone (209)481-9386 Address 2480 Toste Road Citylstate/Zip Tracy,CA 95377 C-57 Contractor Krazan&Associates.Inc. License# 499908 Phone (559)348-2200 Address 215 West Dakota Avenue City/StatelZip Clovis,CA 93612 Consultant/Sub-Contractor RMA GeoScience,Inc. License# GF,2353 Phone (559)288-2652 Address 3897 N.Ann Avenue City/State/Zip Fresno,CA 93727 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bodngs/JVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING 91 HOLLOW STEM BORING DEPTH 20'and 50' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor)water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 7 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS N/A TYPE OF CASING: El STEEL❑PVC ❑ OTHER 5d SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Ole: Casing Dia: Casing Depth: ❑ INJECTION IAFsoaae.emnal ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WEW SOIL BORING IDs B-9 and B-10 GROUT SPECIFICATION Neat Cement and Water 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: We will be drilling two borings and obtaining soil samples as part of the geotechnical investigation that is being done for a new project(see attached site plan for boring locations). I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Jqm ounty Ordinance Codes and Standards,and all other applicable California laws. Signed a Title/Company Principal Geotechnical Engineer Print NameGe Date 2/10/2017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: FanilitviSite Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authoduton for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Peroil ❑Access Agreement ❑Lead Agency Approval El MFR COMMENTSICON DITIONS: SR TYPEPE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit $139 x EHD 29-01 10-26-2015 Site Mitigation Well Permit Application