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SAN JOAOuIN Environmental Healt P - <br />COUNTY- <br />Great, DEC U 2017 <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIC),„1,.,Kk <br />5 <br />NMENTAL HEALTH <br />For Wells and Borings Used for Contaminant Investigations and Remediat1eRM1T/SERVICES <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 work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address <br />Cross Street <br />407 Spreckels Ave <br />Pheonix Drive <br />City/State/Zip Manteca, CA 95336 Phone <br />APN 022-125-035 <br />Property owner AKF Development Holdings LLC Phone <br /> <br />Address 1463 Moffat Blvd City/State/Zip Manteca, CA <br />C-57 contractor Vannucci Technologies License# C-57# 814760 Phone (530) 219-2641 <br />Address P.O. Box 791 City/State/Zip Woodland, CA 95776 <br />License# C-57 # 467252 Phone (916) 366-1701 Consultant/Sub-Contractor Kleinfelder <br /> <br />Address 2882 Prospect Park Dr., Suite 200 City/State/Zip Rancho Cordova, CA 95670 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE 8 El <br />El SOIL BORING 18 <br />ID INJECTION (Air Saarae, °zonal <br />OTHER <br />WELL/ SOIL BORING IN <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />ID Yes IR No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE RI PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Bentonite chips mix(Vapor probes); Neat cement grout (Soil borings) <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />25' <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS U HOSE El PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />D PRESSURE GROUT To depth of feet below surface <br />EJ EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Staff Geologist, Kleinfelder <br />Print Name Anthony Wohletz Date 2017-12-04 <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br /> <br />‘04u-kko•-• <ten-A-- L <br /> <br />Destruction Inspection By/Dates: <br /> <br />FA Name 5 chsw , FA Address 0 7 Spreztc44. At FA# c-oz4 3 ci / PR# o vizet u-- <br />2- I/ FA PE c '4.6 S' WP Reviewed By <br />r"------ <br />Work Plan Date <br /> <br />ce-c: 0 C-57 Authorization for Other to Sign Permit g‘ker's Comp 0 Worker's Comp Waiver 0 Encroachment Pe rrnit 0 Access Agreement ead Agency Approval la< R <br />COMMENTS/CONDITIONS: I Apo( pc-0 )2rz_..) imi,L,S+ be_ uvrx- txtrit_cf e.A.A4 <br />rke_zot evy,"4.,..,,4--, Ad /4%1 fliopict-e-d otv-riv- r -ov4-1\A-3 pAA4 4 - - - -1-re-__ copiv-ad ok ,v-ea eel-41;4m( <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECNI'D BY DATE WELL PERMIT# INVOICE# <br />Permit Vto S-- t>/ ., $152 x ? t 4' S-t 0 24s-- r-1/1/7/0 0 0-0377/ 1 <br />1,4868XA-01...i!Iton Avenue I Stocktonf,f5ng 95205 I T 209 468-3420 I 209 40138061/xi Oom <br />EHD 29:01 0,641 Site Mitigation II P it Application <br />Signed