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r SAN.d0A N EnvironmeilLal Health Department <br /> —COUNTY— <br /> a:L .r <br /> Crentness Oroivs here, <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections f t b� D33 <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 23577 S.Mountain House Parkway City/State2ip TRACY,CA 95304 Phone 909-617-1177 <br /> Cross Street HWY 205 APN 209-080-28 <br /> Property Owner' Mr. Mike Sandhu Pnone209-612-1127 <br /> Address 31995 S. Chrisman Rd -City/State/Zip Tracy,CA95304 <br /> C57 Contractor TERRACON CONSULTANTS INC License# 669004 Phone 209-367-3701 <br /> Address 902 INDUSTRIAL WAY City/State/Zlp LODI CA 96240 <br /> ConsultanVSub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: O#site Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING HOLLOW STEM BORING DEPTH loft-20ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION NaporWater) ❑ RAMMERIDRIVEN Dm.OF BOREHOLE 3 5 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL[I PVC ❑ OTHER <br /> $SOIL BORING =0 PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dix. Casing Dia: Casing Depth: <br /> ❑ INJECTION lArSexree.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE (I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Ma)dmum Freston Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS_NF AT CFMFN7 TO St IRFAC <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with <br /> _ San'Joaquin County <br /> /Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed � ��,�1/ J//�� Title/Company TERRACON CONSULTANTS INC <br /> Print Name Tony Mikacich Date November 13,2019 <br /> PAKIMENT USE ONLY ^ <br /> Application Accepted By: Date Issued: Y <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dales: <br /> Facilit /Site Information /Iyy11••�,�,, (� I` e� <br /> FA Name �, U $fD.CIWs `qrM FA Address � .�-S•MO �t FA# D� I `���ID PR#MAPProval [] <br /> FA PE 2q � WP Reviewed ByI I-t� Work Plan Dale ' I <br /> C57 ❑C57AulhorkalbnforOtMrtoSignPermit ❑Workefs�Co/m�p ❑WorkersCompWaiver ❑EnaoachmentPermit ❑Access Agrcemenl ❑Lead Agency <br /> COMMENTSICONDITIONS: C� IDS <br /> WP TYPE PE SC / FEE INFO "-'A�MT REMITTED MRECV`D BY D TE WELL P�E`RMIT# INVOICE# <br /> Permit ,79os 3Q3 $152x "f 5- �u� II '� ill �►0 3 <br /> 1 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> END 2g-07 09-01-17 She Miageaon Well Perma Applioa0on <br /> Lh _ _ 61711 (n <br />