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SAN vJ0 A Q U I N Environmental Health Department T � SITE MITIGATION WELL & BORING PERMIT APPLICATION For Welts 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 16888 McKinley Road City/State/Zip Lathrop/CA/95330 Phone 209-858-3365 Cross Street Lague Road APN 19816026 Property Owner• Super Store Industries Phone 209-858-3365 Address 16888 McKinley Road City/State/Zip Lathrop/CA/95330 C-57 Contractor Gregg Drilling,Inc. License# 485165 Phone 925-313-5800 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/State/Zip Rancho Cordova,CA 95670 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (29 MONITORING 8 ❑ 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(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing DiaCasing Depth ❑ INJECTION(Air Sums crone) Cl HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED- ❑AUGERS ❑HOSE Q PIPE ❑ OTHER © OTHER: Sonic GROUT SEAL PUMPED? ©Yes❑No (Note:Maximum Freefall Depth is 30 Fl) WELL/SOIL BORING IDs PW-37,PW-38.PW-39.PW-40,PW-41,PW-42 GROUT SPECIFICATIONS Type 11-V DESTRUCTION WORK TO BE PERFORMED: DESTRUC11ON METHOD:(CHECK ALL THAT APPLYI #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 Ej AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP 0 3 feet below surface or feetbeiow surface if>3 feet COMMENTS: 8 monitoring wells will be installed to a maximum depth of 300 ft bgs. 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 Geologist/Geosyntec Consultants,Inc. Print Name Garrett Thornton Date June 29,2018 DEP RTMENT USE ONLY Application Accepted By: Date Issued: ' Grout Inspection By/Dates: Destruction Inspection By/Dates: FacilitvISite Information FA Name S I,,, ii,� FA Address �� 11 � � � ( FA# -�.� rr PR# u-�I mair FA PE Zq b� WP Reviewed By ^ Work Plan Date j '�Ir/ EIC-57 57 Autho izat on for Other tc Sign Permit orkers Comp ❑Workers Comp Waiver ❑/Encroachment Permit Access Agreement �t read Agency Approval p�101�R COMMENTS/CONDITIONS: WP TYPE I PE SC I FEE INFO JAMT REmiTTED1 CHECK#I RECv'�D/BY DATWELLWELL PERMIT# INVOICE# Permit �t71 13 $152x r7l,: 0 �I�( L—�C I?/j1r)1,0,03�S�sfo 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHE 2MI 08-01-17 Site Mitigation Well Permit Application