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SAN J O A Q U IN Environmental Health Department --COUNTY- Greatness grows her, 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/Zip Rancho Cucamonga,CA 91730 Consultant/Sub-Contractor Geosyntec Consultants,Inc. License# Phone 916-637-8334 Address 3043 Gold Canal Dr. City/State/Zip Rancho Cordova,�,A`95670 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS L29 MONITORING t ❑ HOLLOW STEM BORING DEPTH Up to 300 ft bgs ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: []STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(G T) CONDUCTOR CASING ❑Yes 'No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soxge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: E]AUGERS I—]HOSE ©PIPE ElOTHER ® OTHER: Sonic G UT SEAL PUMPED? ® es El No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs PW-40 GROUT ECIFICAT11(0 Type II-V DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-SORE DIAMETER of inches to depth of feet WELL IDs E]PRESSU4-(:�ROUT To depth of feet below surface GROUT SPECIFICATIONS ❑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: One monitoring well will be installed to a maximum depth of 300 ft logs. See attached table with well specifications. 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 Professional/Geosyntec Consultants, Inc. Print Name Garrett Thornton Date September 28,2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name �e FA Address 1 4111 7-1 (2-Cl� FA# PR# FA PE o��'' WP Reviewed By iWork Plan Date `7 ❑C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver 13 Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ©MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 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