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SAN WOUIN r-" virenrr,--'ital 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 Roquir=t: For All inspections Applicatlon 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 16777 Howland Road CltylState/Zip City/State/ZipLathro /CA195023 phone 209-858-2511 Cross Street APN 19818008 Property Owner' _ - _ a _- Phone Address _ - _ — _ _ CitylState/Zip C-57 Contractor Gregg Drilling,Inc_ License# 485165 _ Phone 925-31_3-_5.800 Address 950 Howe Road City/State/Zip Martinez,CA 94553 Consultant/Sub-Contractor Geosyntec Consultants,Inc. License# _ _ _ Phone 916-637-8334 Address 3043 Gold Canal Dr City/Stato/zip Rancho Cordova.CA 95670 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits TYPE OF WE LIS RING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING I Cl HOLLOW STEM BORING DEPTH Up to 300 ft boa ❑BOLTED TRAFFIC BOX ©STOVE PIPE ❑ EXTRACTION(Vapor/Water) U HAMMERIDRIVEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 4" ❑ SOIL VAPOR PROBE t-1 MUD ROTARY CASING THICKNESS-77' TYPE OF CASING: M STEEL❑PVC ❑ OTHER ❑SOIL BORING Lj PUSH POINT(GP/CPH CONDUCTOR CASING ❑Yes❑No Nr;i.i P:n C,ejM rAY. r re�,g tfapds _ ❑ INJECTION(r.:, uarr Cl HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE M PIPE ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? ®Yes❑No (Note:Maximum Freefall Depth is 30 FI) WELU SOIL BORING IDs PW43,PW44 GROUT SPECIFICATIONS Type ll-y DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION MIET1IOD:tr:rti cicALL I11,;f Arh;.Y: #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_ _ I--]EXPLOSIVES From _to_-_-feet below surface TREMIE TYPE TO BE USED AUG ❑tie)SL []PIPE ❑MUSHROOM CAP CI 3 feet below surface or _feel below surface if>3 feet ERS OMili 8 monitoring wells 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 application and that the work will be done In accordianca with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Geologist/Geosyntec Consultants,Inc. Prini N u e Garrett Thornton Date June 29,2018 DEPARTMENT USE ONLY Application Accepted By: _ Date Issued {1 Grout Inspection By/Dates: Destruction Inspection By/Dates: _ _ _ ___. _ __ 'J "' •V� / Faclllt 1Slto Information FA Name M FA Address I(��71 �O u y,a � (� FA# e 0 Z,-{-1 PR# cy 13 s g FA PE yGi io S WP Reviewed By L, X Work Plan Date G I Z'L ❑C-57 LR.-57 Authorization for Other to Sgn Permit [[�O�orker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement mad Agency Approval M FR COMMENTSICONDITIQNS: WP TYPE PE 1 Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE t WELL PERMIT# INVOICE# Permit �O l 313 5152 x 2 11119 1868 E, Hazelton Avenue 1 W Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD1-17 SPermit Application ; 53 4IZX3 L — [- 7IZjl� J? ��OOIJOa