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SAN ZJ0 A Q U IN Environmental Health Department <br /> COUNTY <br /> r <br /> v `FOR. GrPOrrlASs q•^wS �?r'-., <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Approximately 16200 McKinley Ave. City/State/Zip Lathrop, CA 95330 Phone NA <br /> Cross Street East Louise Avenue APN NA,City of Lathrop Right of Way <br /> Property Owner* City of Lathrop Phone 209-941-7430 <br /> Address 390 Towne Centre Drive City/State/Zip Lathrop, CA 95330 <br /> C-67 Contractor Gregg Drilling License# C-57: 1044456 Phone 925-313-5800 <br /> Address 950 Howe Road City/State/Zip Martinez, CA 94553 <br /> Consultant/Sub-Contractor Geosyntec, Inc. License# NA Phone 916-637-8048 <br /> Address 3043 Gold Canal Drive, Suite 100 city/state/Zip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [R MONITORING 1 HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX STOVE PIPE <br /> El EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE �— [I❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2" <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ®STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soaae,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs Boring:B-11 GROUT SPECIFICATIONS <br /> Well:PW46-76 Neat Grout Cement(Portland Type II-V)mix <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> One monitoring well will be installed to a maximum depth of 80 feet bgs.See attached figure with well design specifications. <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed_;j� � Title/Company Senior Geologist/Geosyntec Consultants,Inc. <br /> Print Name Nicole Gotberg Date June 10,2019 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Nakc-- Date Issued: 0-0G—/7 <br /> Grout Inspection By/Dates: 1 <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address Abo6, to/G qvr /Dfe4ftA„t FA# epe 1633 PR# �el x <br /> FA PE L 610 WP Reviewed By Work Plan Date <br /> C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver &Encroachment Permit ❑Access Agreement [jKead Agency Approval 0T9FR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit L 10( X13 $152 x ! 1116'Z.•GY­-) 1177 AA I 4-t-6-tq wpoa3f 742 <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />