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SAN JOAQUIN COUNTY �--� V_ ENVIRONMENTAL HEALTH DEPARTMINIT s1cp ®. 1868 Hazelton Avenue, Stockton, CA 95205-6232 EhrVjROhn 7 2016 rq P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.COM `��F o�•� FRM1TiSF�yFALTy SITE MITIGATION WELL & BORING PERMIT APPLICATION VICES 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 20500 Holly Drive City/State/Zip Tracy,CA,95304 Phone N/A Cross Street APN Property Owner* Cortese Real Property(Steve Cortese) Phone Address 21 Lafayette Circle,Suite 200 City/State/Zip Lafayette,CA,95449 C-57 Contractor Woodward Drilling License# 710079 Phone 707-374-4300 Address 550 River Road City/State/Zip Rio Vista,CA,94571 Consultant/Sub-Contractor Langan Treadwell Rollo License# Phone 415-955-5200 Address 555 Montgomery Street,Suite 1300 City/State/Zip San Francisco,CA,94111 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: Cl AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED Four 4"wells;three 6"wells ®OVER-BORE DIAMETER of 4 inches to depth of 45 feet;diameter of 6"t, WELL IDs WP-1 through WP-7(see attached figure) ❑PRESSURE GROUT To depth of feet below surface depth of 100' GROUT SPECIFICATIONS neat cement grout ❑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: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with arjJioa�lUin County Ordinance Codes and Standards,and all othr applicable California laws. Signed / Title/Company VAr ^� Print Name C l�W Date h, ice: Cr "14", / DEPARTMENT USE ONLY Application Accepted By: lie_ &�h Date Issued: h)/7// ) 7 / r� Grout Inspection By/Dates: w?--r wir-G P-1 M-'k'E 11 lr N Destruction Inspection By/Dates: � Facilit /Site Information FA Name FA Address FA# Qp PR# Ur�f!2& FA PE WP Reviewed By Work Plan Date '7 ! if 20 L b ❑C-57 C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval 0'MI R COMMENTS/CONDITIONS: SR TYPE PE sC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE U `SERVICE REQE�ST# INVOICE# Work Plan 29113 5Z 3 �1 7 /��7 Z�S� 6VT< -5k,00 Y- c Permit Z96 2 3 13 $130 x s (� 5 2653 6-VT2 SjPOo 7f9,0 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application