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COUNTY- <br />Grecitness grows here. <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />SITE MITIGATION WELL & BORING PERMIT APPLICATEla <br />For Wells and Borings Used for Contaminant Investigations and Remedia <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the wo described. <br />This application Is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the S Joaquin County Well Standards. <br />Job Address 407 Spreckels Ave City/State/Zip Manteca, CA • 336 Phone <br />Cross Street Pheonix Drive APN 022-125-035 <br />Property Owner* AKF Development Holdings LLC <br />Address 1463 Moffat Blvd City/State/Zip ___Mantpca, CA <br />C-57 Contractor Vannucci Technologies LIcenseit C-57# 814760 Phone (530) 219-2641 <br />Address P.O. Box 791 City/State/Zip W odland, CA 95776 <br />Consultant/Sub-Contractor Kleinfelder License# C- # 467252 Phone (916) 366-1701 <br />Address 2882 Prospect Park Dr., Suite 200 <br />Date 2017-12-04 Print Name Anthony Wohletz <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Re re Access Agreements or Encroachment Permits <br />O BOLTED TRAFFIC BOX ID STOVE PIPE <br />MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DR <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />No Boring Dia: Casing Din: Casing Depth: <br />TREMIE PIPE TO BE USED: 0 AUGERS El HOSE 14 PIPE <br />El Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />Bentonite chips mix(Vapor probes); Neat cement grout (Soil borings) <br />NUMBER INSTALLATION TYPE CONSTRUCTION <br />HOLLOW STEM BORING DEPTH <br />HAMMER/DRIVEN DIA. OF BORE <br />MUD ROTARY CASING TH IC <br />Di PUSH POINT (GP/ CPT) CONDI CTOR <br />El HAND AUGER GROU' SEAL DE <br />E1 OTHER: GROU EAL P <br />GROUT <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION Or Sparge, Ozonel <br />OTHER <br />WELL/SOIL BORING IDs <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />)? WELLS TO BE DESTROYED DOVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />bereby,eartIfytnat,lAtil al09.rjzft P.P9700.1#1.4 aPP.4atlon,and t.i?4 thow.fa* will be done In accordance with <br />, San 'Joaquin :County pr nance Codes and Standards,"and 41.10* appItcaldle California taWs. '- <br /> Title/Company Staff Geologist, Kleinfelder <br />18 <br />Signed <br />DEPARTMENT USE ONLY <br />Destruction Inspection By/Dates: <br />Facility/Site information <br />FA Name FA Address FA# PR!! <br />FA PE WP Reviewed By Work Plan Date <br />El C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />MENTAL HEALTH <br />IT/SERVICES <br />Phone <br />City/State/ZI • Rancho Cordova, CA 95670 <br />Environmental Healt <br />DEC ti 5 2017