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SAN J O A Q U I N Environmental Health Department 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 Approximately 16353 McKinley Ave City/State/Zip Lathrop/CA/95330 Phone 209-858-3365 Cross Street Louise Avenue APN NA-City right-of-way Property Owner' The City of Lathrop,California Phone 209-858-3365 Address 16888 McKinley Road City/State/Zip Lathrop/CA/95330 C-57 Contractor Yellow Jacket Drilling Service LLC License# 1034407 Phone 909-989-8563 Address 9460 Lucas Ranch Road City/State/Zlp Rancho Cucamonga.CA 91730 Cons ultant/Sub-Contractor Geosyntec Consultants,Inc. License# Phone 916-637-8334 Address 3043 Gold Canal Dr. City/State/Zip Rancho Cordova,CA 95670 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS IN MONITORING 1 ❑ HOLLOW STEM BORING DEPTH Up to 3D0 ft bgs ®BOLTED TRAFFIC BOX ❑STOVE PIPE 11 ❑ EXTRACTION(VaporMlater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: a�'STEEL❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes❑No Boring Dia: Casing Dia: Casing 090: ❑ INJECTION wsoma,omal ❑ HAND AUGER GRCUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IN PIPE ❑ OTHER ZI OTHER: Sonic GROUT SEAL PUMPED? IN Yes ❑No (Note:Maximum Freetall Depth is 30 Ft) WELUSOIL BORING IDs PW-40 GROUT SPECIFICATIONS Type II-V 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 [—]AUGERS ❑HOSE []PIPE ❑MUSHROOM CAP 0 3 feet below surface or feet below surface if>3 feet COMMENTS: One monitoring well will be installed to a maximum depth of 300 ft bgs. See attached table with well specifications. I hereby certify that 1 am authorized to complete this applicatlon and that the work will be done in accordance with San Joaq a GpuA rdinance C Standards,and all other applicable California laws. Signed V Title/Company Professional/Geosyntec Consultants, Inc. Print Name Garrett Thornton Date November 5,2018 EPARTMENT USE ONLY Application Accepted By: Date Issued: v" I x/11 Grout Inspection By/Dates: Destruction Inspection By/Dates: FacilltvISIts Information FA Name S I FA Address (o7�7 t t i Ju��r_,I FA# 00 1--1124 PR# AV FA PE Ct � WP Reviewed By �� `��[ 1/ Work Plan Date {p ZZ / ❑C-57 57 Authorization for Other to Sign Permit Fal orkers Comp ❑Worker's Comp Waiver ❑Encroachment Permit pKccess Agreement U,Eead Agency Approval FR COMMENTS/CONDITIONS: WP TYPE PE� SC FEE INFO AMT REMITTED CHECK# RECD DATE WELL PERMIIT# INVOICE# Permit j j'3 $152 x 4 /SZ 11,i 1-- —J� 1 /t r`j i 38 �J 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