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SAN J O A Q U I N Environmental Health Department C O U N T Y------- 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 48 Hours Advance Notice Required For All 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 25775 South Patterson Pass Road City/State/Zip Tracy Phone Cross Street 1-580 APN 20910014,20910024(B-51) Property Owner' The Robert and Cleo Vieira Family Trust Phone 925-754-2991 Address 1131 West Bowman Road City/State/Zip Stockton,CA 95231-9612 C-57 Contractor Gregg Drilling and Testing License# C57485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez,CA 94553 Consultant/Sub-Contractor Arcadis License# Phone 916-865-3171 Address 101 Creekside Ridge Court, Suite 200 City/State/Zip Roseville, CA 95678 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING (] HOLLOW STEM BORING DEPTH 10 to 70 ft bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER E) SOIL BORING 9 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) 12 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 B-49,B-50,B-51,B-52,B-53,B-54,B-55, GROUT SPECIFICATIONS Neat cement from bottom of boring to 6 inches below ground surface. B-56,B-57 Asphault patch from 6 inches below ground surface to surface. 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 E]AUGERS [-]HOSE [IPIPE [:]MUSHROOM CAP [-13 feet below surface or feet below surface if>3 feet COMMENTS: Borings B-49,B-50,B-51,B-52 and B-53 advanced to approximately 70 feet bgs. Borings B-54,B-55,and B-56 advance to 10 ft.bgs.Boring B-57 advanced to 13 ft.bgs. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Associate Project Manager Print Name Sherrie Lang Date May 18,2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# T PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PESC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# Permit $152 x I I d 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 08-01-17 Site Mitigation Well Permit Application